ARTHUR  E.   HERTZLER,  M.D. 
SECOND  EDITION 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 
Robert  Huebert 


SURGICAL  OPERATIONS 

WITH 

LOCAL  ANESTHESIA 


SECOND    EDITION 


BY 

ARTHUR  E.  HERTZLER,  A.  M.,  M.  D., 
Ph.  D.,  F.  A.  C.  S. 

Surgeon  to  the  Halstead  Hospital,  Kan.,  the  Swedish  Hospital,  Kansas 
City,  Mo.  and  to  the  General  Hospital,  Kansas  City,  Mo. 


SURGERY    PUBLISHING  COMPANY 

!I2   WILLIAM   STREET 

NEW   YORK 

1916 


Copyright,  1916 

By 

SURGERY    PUBLISHING  COMPANY 
New  York 


Bwmedical 
Library 

loo 

300 

PREFACE. 


In  the  first  edition  of  this  little  book  I  had  in  mind  the  needs 
of  the  general  practitioner  in  the  role  of  an  "occasional  opera- 
tor." In  harmony  with  this  plan  the  simpler  operations  alone 
were  described,  confining  myself  to  those  operations  which  any 
one  should  be  able  to  do  with  certainty  without  a  great  amount 
of  experience  in  the  use  of  local  anesthetics. 

Contrary  to  my  expectations  many  surgeons  of  standing  ex- 
pressed an  interest  in  the  work  and  made  the  suggestion  that 
its  scope  be  widened  to  meet  the  need  of  surgeons.  In  conform- 
ity with  this  wish  the  present  work  takes  in  most  of  the  major 
operations. 

In  acceding  to  the  demands  of  a  wider  scope  I  have  not  de- 
parted from  the  original  plan  of  presenting  to  the  reader  a  mul- 
titude of  detail  which  seeks  to  arm  the  operator  with  a  broad 
range  of  procedure  which  makes  it  possible  to  select  that  which 
is  best  for  the  given  condition  and  patient.  In  order  to  attain 
this  aim  it  has  been  necessary  to  outline  the  entire  course  of  the 
operation  in  many  instances.  This  is  necessary,  for  in  but  few 
procedures  is  any  technic  absolutely  certain  in  the  hands  of  all 
classes  of  operators.  For  instance,  the  skilled  operator  in  a 
hernia  operation  is  able  to  block  off  the  nerve  supply  with  cer- 
tainty before  the  operation  is  begun.  The  less  experienced  will 
find  that  in  the  course  of  the  operation  some  detail  has  failed  to 
work  out  according  to  schedule.  It  becomes  necessary  to  supple- 
ment his  preliminary  injections.  This  book  attempts  to  tell  the 
operator  just  how  to  help  himself  out  in  these  little  perplexities. 

The  literature  bearing  on  local  anesthesia  has  been  collected 
with  diligence  and  has  played  an  important  part  in  the  develop- 
ment in  the  procedures  as  here  set  forth,  and  I  gladly  acknowl- 
edge my  indebtedness.  The  operations  as  presented,  however, 
are  the  result  of  my  own  experience  and  I  stand  sponsor  for  their 
efficiency  if  performed  as  advised.  For  this  reason  the  litera- 
ture has  been  specifically  cited  only  in  instances  where  the  pro- 
cedure is  as  yet  not  fully  satisfactory.  This  is  done  in  order 


706082 


that  the  reader  may  refer  to  the  original  papers  in  order  to  se- 
cure first-hand  the  original  conception  of  the  operation. 

The  purely  practical  scope  of  the  book  absolves  me  from  any 
obligation  to  note  the  history  of  local  anesthesia.  Furthermore, 
those  who  have  been  most  interested  in  local  anesthesia  will 
agree  with  me,  I  am  sure,  that  we  are  as  yet  only  constructing 
an  alphabet  and  that  until  the  fundamentals  are  more  completely 
worked  out  the  writing  of  the  story  is  not  profitable. 

I  have  omitted,  too,  any  discussion  of  the  theory  of  the  pro- 
duction of  local  anesthesia.  This  involves  a  discussion  of  the 
nature  of  pain  and  the  problem  of  osmosis.  I  am  forced  to  with- 
go  such  a  discussion  because  I  know  nothing  about  it,  and  there 
is  not  available  to  me  any  presentation  of  the  subject  which 
would  in  any  way  enhance  the  art  of  local  anesthesia. 

The  attempt  has  been  made  throughout  the  book  to  emphasize 
the  need  of  the  utmost  gentleness  in  technic.  This  is  necessary 
if  satisfactory  results  are  to  be  obtained  in  operating  on  our 
sensitive  and  self-assertive  American  patrons.  There  is  a  vast 
range  of  difference  between  the  patients  bearing  the  pain  and 
being  operated  upon  painlessly. 

For  this  reason  I  believe  that  it  is  worth  while  to  modify  the 
technic  as  advised  by  our  Teutonic  brothers,  with  the  idea  of 
avoiding  as  much  as  possible  any  unnecessary  strain  on  the  sen- 
sibilities of  the  patient. 

The  operator  must  approach  his  task  imbued  with  the  spirit 
of  gentleness  in  the  fullest  measure.  He  must  have  an  accurate 
knowledge  of  the  anatomy  of  the  region  he  is  about  to  operate 
upon,  and  above  all  he  must  have  in  his  mind's  eye  the  full  scope 
of  the  required  operation. 

It  is  in  the  constant  emphasis  of  the  above  factors  that  I  have 
hoped  to  find  a  sphere  of  usefulness  for  this  little  book  in  the 
dignified  companionship  of  larger  and  more  pretentious  works. 

It  is  a  pleasure  to  acknowledge  my  great  indebtedness  to  Tom 
Jones  for  the  interest  he  has  shown  in  the  preparation  of  the 
illustrations. 

A.  E.  H., 
1310  Rialto  Building. 


CONTENTS 


CHAPTER   I. 

DRUGS    EMPLOYED .PA°f 

Cocain i 

Quinine   and   Urea   Hydrochloride    7 

Novocain     15 

Epinephrin 20 

Sequential   combination   of   Local   and   General   Anesthetics    19 

Combined  Local  and   General  Anesthesia    22 

CHAPTER   II. 

TECHNIC    OF    ADMINISTRATION    25 

Syringes    Used    25 

General    Preparation    of   the    Patient    28 

Technic    of    Injection     •  • 31 

Intravenous   Anesthesia    39 

CHAPTER   III. 
LOCAL    ANESTHESIA    IN    THE    PREVENTION    OF    AFTER-PAIN    AND 

SHOCK     44 

CHAPTER  IV. 

GENERAL  OPERATIONS  58 

1.  Opening  of  Abscesses    •  • 58 

2.  Removal    of    Tumors    59 

3.  Search    for    Foreign    Bodies    •  • 62 

4.  Skin     Grafting     62 

CHAPTER  V. 

OPERATIONS   ON   THE  CRANIUM    64 

1.  Operations  on  the    Cranial   Soft   Parts    64 

2.  Wounds  of  the   Scalp 66 

3.  Removal    of   Tumors    67 

4.  Operations    on    the    Skull    70 

5.  Operations    on    the    Cranial    Contents    72 

CHAPTER    VI. 

OPERATIONS  ON  THE  FACE  AND  JAWS    ••.  73 

1.  Operations   on    the   face   and   orbit    •  • 73 

2.  Operations  on  the  soft  parts   76 

3.  Operations   on   the   upper  jaw 77 

4.  Operations  on  the  lower  jaw   8 1 

5.  Excision  of  the  cervical  glands  85 

6.  Operations  on  the  tongue    90 

7.  Tumors  of  the  floor  of  the  mouth   92 

8.  Operations  on  the  buccal  soft  parts    92 


Contents 

CHAPTER    VII. 

OPERATIONS  ON  THE  EAR  AND  MASTOID   93 

1.  Operations    on    the    Ear    93 

2.  Mastoid    Operations    94 

CHAPTER   VIII. 

OPERATIONS   ON   THE   GASSERIAN   GANGLION    99 

1.  Operations  on  the  First  Branch   •  • 106 

2.  Operations  on  the  Second  Branch   no 

3.  Operations  on  the  Third  Branch   •  • 112 

CHAPTER    IX. 

OPERATIONS    ON    THE   TONSILS   AND   ADENOIDS    116 

Operations   on   the  Tonsil    •• 116 

Operations    on    the    Adenoids    118 

CHAPTER   X. 

OPERATIONS    ON    THE    THYROID    AND    LARYNX    119 

Neural  Anatomy  of  the   Neck    •• ng 

Tracheotomy     121 

Extirpation    of    the    Larynx    •  • • 123 

Laryngotomy      123 

CHAPTER   XI. 

OPERATIONS  ON  THE  MAMMARY  GLAND   133 

Nerve    Supply    •  • 133 

Opening   of   Abscesses    133 

Benign     Tumors     •  • 133 

Diagnostic   incision    of    Breast    134 

Radical    Breast   Amputation    •  • 137 

CHAPTER    XII. 

OPERATIONS    ON   THE   THORAX,   LUNGS,    SPINE   AND   KIDNEYS    ....  141 

1.  Nerve  Supply  of  the  Thorax   141 

2.  Operations    on    the    Spine    143 

3.  Operations   on   the   Thorax — Thoracoplasties    144 

4.  Operations   on   the    Mediastinum    155 

5.  Operations   on   the   Kidneys  and   Ureters    158 

CHAPTER    XIII. 

ABDOMINAL    OPERATIONS     161 

Nerve   Supply  of  the  Abdomen    1 64 

Exploratory     Operations     170 

Gastrostomy      •  • 175 

Gastroenterostomy     176 

Colostomy     178 

Appendectomy      1 79 

Gall-bladder    Operations    180 


Contents 
CHAPTER  xiv. 

OPERATIONS    FOR   UMBILICAL    HERNIAS,    HERNIAS    OF    THE   LINEA 

ALBA   AND    SCAR    HERNIAS    182 

Umbilical    Hernias    182 

Hernias  of  the  Linea   Alba    186 

Scar    Hernias    •-....    186 

CHAPTER    XV. 

OPERATIONS    FOR    HERNIAS    188 

Inguinal     Hernia     •  • 188 

Femoral     Hernia     204 

CHAPTER    XVI. 

SACRAL    BLOCKING    208 

Solutions    used     •• 211 

Duration  and   Extent  of  Anesthesia    212 

Efficiency    and    Failures    •• 213 

CHAPTER   XVII. 

OPERATIONS   ON   THE   PENIS    •• 216 

Circumcision     216 

Amputation    of   the    Penis    •  • 220 

CHAPTER   XVIII. 

OPERATIONS   ON    THE   SCROTUM   AND   ITS   CONTENTS    222 

Varicocele      222 

Amputation   of   the   Scrotum    •  • 229 

Hydrocele      230 

Vasectomy      231 

CHAPTER    XIX. 

OPERATIONS  ON  THE  URETHRA,  BLADDER  AND  PROSTATE   233 

Local    Anesthesia    preliminary    to    Cystoscopy    233 

External    Urethrotomy     •  • 233 

Suprapubic     Cystotomy      234 

Stone  in  the   Bladder  and   Ureter    235 

Removal    of   the    Prostate    •  • 235 

CHAPTER   XX. 

OPERATIONS    ON    THE    FEMALE    GENERATIVE    ORGANS    240 

Repair   of   the   Cervix 241 

Curretage   of  the  Uterus    243 

Ilystcrotomy     •  • 245 

Anterior    Colporrhaphy    % •  • . .  .   248 

Repair    of    the    Perineum    250 

Nerve   Supply   of  the   Perineum    •  • 251 

Operations    on    the    Vulva     260 


Contents 

Freund-Wertheim    Operation     260 

Palliative    Operations   for    Carcinoma    of   the   Uterus    261 

Shortening  of  the  Round  Ligaments  261 

Urethral   Caruncle    262 

CHAPTER    XXI. 

OPERATIONS  ABOUT  THE  RECTUM  264 

Dilatation  of  the   Sphincter    270 

External     Hemorrhoids     •  • 267 

Internal    Hemorrhoids     270 

Fistula    in    Ano    •  • 275 

Carcinoma    of    the    Rectum    280 

CHAPTER   XXII. 

OPERATIONS    ON    THE    EXTREMITIES    282 

Infections  of  the   Extremities    •  • 282 

Fractures  of  the   Extremities    283 

Operations   on   the   Hand   and   Arm    287 

Plexus     Blocking     295 

Operations    on    the    Foot    and    Leg    •  • 1299 

Varicose   Veins  and  Ulcers    306 

Patellar    Bursitis     •• 310 


ILLUSTRATIONS 


FIGS.  PAGE. 

1.  Ethyl     chloride    container     23 

2.  Glass  .barrel    metal    mounted    syringe    25 

3.  Five    cc.    Record    syringe    26 

4.  All    metal   syringe    with   extension    26 

5.  All    metal    dental    syringe     27 

6.  Proper  method  of  picking  up  fold  of  skin  in  beginning  infiltration    31 

7.  Wheal    production    by    endermic    infiltration     "   32 

8.  Position    of   needle   in    endermic    infiltration    33 

9.  Subdermic     infiltration     35 

10.  Method    of    picking   up    a    nerve    for    endoneural    injection    36 

1 1.  Showing   line    of   infiltration   over    summit    of   a    wen    59 

12.  Showing  method   of  edematization   of  the   base   of  a  tumor    60 

13.  Method   of   injecting   the   skin   about   the    base   of   a   benign   tumor    60 

14.  Distribution    of    the    nerves    supplying    the    scalp    65 

1 5.  Incision   about   a    Hemangioma    69 

1 6.  Skin  grafting  after  removal   of  Hemangioma  in   preceding  fig 69 

17.  Primary    infiltration   in   the   cranial   flap   operation    71 

18.  Nerve  supply   of  the  palatal  surface   of  the  upper  jaw    74 

19.  Nerve  supply  of  the  jaw,   upper   surface    75 

20.  Nerve    supply    of   the    lower   jaw    77 

21.  Direction   of  the   needle   in   the   anesthetization   of  the   upper   teeth    77 

22.  Showing  the  relation  of  the  beveled  edge  of  the  needle  to  the  bone  surface  77 

23.  Line  of   skin   infiltration   for   resection  of   the  upper  jaw    80 

24.  Injection   of   fluid   about   the    roots   of   the   teeth    82 

25.  Point    of    injection    for    the    premolar    teeth     83 

26.  Relation  of  the  tip  of  the  needle  to  the  lingulum   83 

27.  Relation  of  the  syringe  and  needle  in  nerve  blocking  at  the  lingula   84 

28.  Infiltration    for    operation    for   a    dentigerous    cyst    85 

29.  Line  of  infiltration  for  the   removal   of  the   cervical  lymph   glands   86 

30.  Point  of  infiltration  in  front  of  the  carotid  sheath   87 

31.  Line    of    infiltration    for    excision    of   the   jaw    89 

32.  Blocking   the    base   of  the   tongue    91 

33.  Line  of  infiltration  for  the   mastoid  operation    95 

34.  Deep  infiltration  into  the  auditory  canal    96 

35.  Cross   section   of   the   preceding    96 

36.  Neumanns    method    of    anesthetizing    the    tympanum    97 

37.  Direction  of  the  needle  in  Gasserian  blocking  101 

38.  Direction   of   the  needle   in   Gasserian    blocking    102 

39.  Direction   of   the   needle   in    Gasserian   blocking    103 

40.  Direction  of  the  needle  in  Gasserian  blocking   104 

41.  Direction  of  the  needle  in  Gasserjan  blocking  105 

42.  Direction  of  the  needle  in  Gasserian  blocking   106 

43.  Direction  of  the  needle  in  blocking  the  nerves  about  the  orbit   107 

44.  Direction   of  the  needle   in   blocking  the   Gasserian  ganglion    108 

45.  Direction   of   the   needle   through   the   foramen   rotundum    109 

46.  Direction   of  the  needle  for   blocking  the  third  branch    

47.  Points   for  injection   for   tonsilectomy    

48.  Superficial  nerves  of  the  anterior  region   of  the  neck   

49.  Innltratioin  lines  for   tracheotomy    

50.  Skin    infiltration    for    thyroidectomy     

51.  Lateral  view  of  skin  infiltration  for  thyroidectomy   


Infiltration    of   the   deep    tissues   in   thyroidectomy 

Secondary  blocking  about  the  superior  pole  of  the  thyroid  in  thyroidectomy 

Ligation    of   the    superior    thyroid    vessels    

Ligation    of    the    inferior    thyroid    vessels    

Infiltration    for   removal   of   benign   tumors   of   the  breast    

Line   of   infiltration   for   diagnostic   incision    of   the   breast    


Illustrations 

FIGS.  PAGE 

58.  Sliding   of   the   skin   in   the   previous   infiltration    136 

59.  Line   of   infiltration    for    the    radical    breast   operation    138 

60.  Nerve  supply  of  the  abdominal   wall    142 

61.  Infiltration    of    the    deep    layers    in    laminectomy    143 

62.  Author's    laminectomy    trephine    144 

63.  Line   of   infiltration    for   thoracoplasty    145 

64.  Injection    of    the    intercostal    nerves     150 

65.  Partial   elevation   of  the   periosteum   in   rib   resection    151 

66.  Partial    elevation    of   the   periosteum   in    rib    resection    151 

67.  Author's    sinus    dilator     153 

68.  Infiltration  lines   for   operations   on   the   mediastinum    156 

69.  Line  of  infiltration  for  operations  on  the  kidney    159 

70.  Relation  of  the  abdominal  muscles  and  nerves    162 

71.  Elliptic  infiltration  of  the  abdominal   wall    172 

72.  Infiltration    of    the    abdominal    wall     173 

73.  Infiltration    for    appendectomy     178 

74.  Line   of    infiltration    about   an    umbilical    hernia    182 

75.  Line    of    infiltration    about    an    umbilical    hernia    183 

76.  Line    of   infiltration   about   an   umbilical    hernia    184 

77.  First   row    of   sutures   passed   in    operation    for   umbilical    hernia    185 

78.  Second   row   sutures   passed   in   operation   for   umbilical   hernia    185 

79.  Nerve  supply  of  the  inguinal  region   188 

80.  Line   of  infiltration   for  inguinal   hernia    192 

8 1.  High    skin    incision    for    inguinal    hernia    193 

82.  Superficial    deep    epigastric    vessels    194 

83.  Infiltration    of    external    oblique    fascia     194 

84.  Infiltration  of  the   ilio-inguinal   nerve    195 

85.  Blocking  of  the  cord   in   operation  for  inguinal   hernia    196 

86.  Infiltration   of   the   sac   in   inguinal   hernia    197 

87.  Suture    of   the    planes   in    inguinal    hernia    198 

88.  Suture    of   the    planes   in   inguinal    hernia    199 

89.  Nerve  blocking  for  inguinal  hernia  operation    200 

90.  Nerve   blocking  for  inguinal    hernia   operation    200 

91.  Incision   for  constriction   in   strangulated   hernia    201 

92.  Skin    infiltration    for    femoral    hernia    203 

93.  Infiltration    of   tissues    about    Pouparts   ligament    205 

94.  Incision  of  the  constriction  of  strangulated  femoral   hernia    206 

95.  Plan    of    suture    in    femoral    hernia 207 

96.  Position  of  the  patient   in  sacral  blocking 209 

97.  Direction    of   needle   in   sacral   blocking    211 

98.  Line    of    skin    infiltration    for    circumcision    217 

99.  Infiltration   of   mucous  surface   for  circumcision    217 

Injection    of    the    frenum    for    circumcision    217 

01.  Incision   of  the   skin   in  circumcision    218 

02.  Dissection   of  the  mucous  membrane  in  circumcision    218 

03.  Incision   of  the   mucous   layer   in   circumcision    218 

04.  Suture    of    the    skin    in    circumcision    219 

05.  Infiltration  for  amputation  of  the  penis   220 

06.  Infiltration  for  amputation   of  the  penis    221 

07.  Line   of   skin   infiltration  in   operation   for  varicocele    223 

08.  Cord    blocking   in    operation   for   varicocele    224 

09.  Ligation  of  the  vein  bundles  in  the  same    225 

10.  Reunion  of  the  vein  bundles  in  the   same 226 

1 1.  Closing   of   fascia   in   the   same    227 

12.  Closure  of   skin   in   same    228 

13.  Skin    infiltration    for    prostatectomy    238 

14.  Deep   infiltration    for    prostatectomy -239 

15.  Author's   leg   holder    for    perineal    operations    241 

16.  Line   of   infiltration   for  operations  on   the   cervix    242 

17.  Method  of  applying  figure  8   suture  in  lacerated  cervix    243 

1 8.  Method   of   applying  figure   8   in   lacerated   cervix    244 

19.  Line   of   infiltration    for   anterior   colpotomy    245 

20.  Diagnostic    incision     of     cervix     246 

21.  Diagnostic   incision   of   body   of   uterus    247 

22.  Closure    of   the    uterus   after   diagnostic   incision    248 

23.  Second   stage  in  same    249 

24.  Hysterotomy    completed     250 

xii 


Illustrations 

FIGS.  PAGE 

125.  Infiltration   of  the  vaginal   wall  in   anterior  colporrhaphy    251 

126.  Infiltration   of  the  vaginal   wall   in  anterior  colporrhaphy    252 

127.  Infiltration    in    perineorrhaphy    253 

128.  Infiltration     in     perineorrhaphy     254 

129.  Separation    of   the   vaginal   flap   in   perineorrhaphy    255 

130.  Suture   of   the   levator   muscles   in    perineorrhaphy 256 

131.  Suture  of  the  levator  muscles  in   perineorrhaphy    257 

132.  Closure   of   the   perineal    fascia    ; . . .   258 

133.  Closure   of  the   skin    in    perineorrhaphy    259 

134.  Nerve   supply   of  the   perineum    266 

135.  Infiltration    for    external     hemorrhoids     267 

136.  Infiltration     for    external    hemorrhoids     268 

137.  Infiltration    for    prolapsed    internal    hemorrhoids     269 

138.  Skin    infiltration    about    anal    margin    270 

139.  Infiltration    of    the    anal    sphincter    preliminary    to    dilatation    271 

140.  Infiltration   of  the   anal   sphincter  preliminary   to   dilatation    272 

141.  Infiltration   of   the   pedicle   of   pile    273 

142.  Legation    of    the    pedicle    of    pile    274 

143.  Line   of   infiltration   for   fistula   in   ano    276 

144.  Infiltration    of    tissue    about    anal    fistula    277 

145.  Dissection   of   fistulous   tract    278 

146.  Suture   after   the   excision   of   tract    279 

147.  Suture   after   the   excision    of   tract    279 

148.  Infiltration  about  the   ends  of  bones  in   fractures    284 

149.  Infiltration    in    dislocation    of    the    knee    285 

1 50.  Blocking    of    the    digital    nerves    286 

151.  Infiltration    for   amputation    of   the    fingers    287 

1 52.  Infiltration   for   amputation   of  the   fingers    288 

153.  Infiltration   for   amputation   of  the   fingers    290 

154.  Blocking    above    the    wrist    joint    291 

155.  Blocking    above    the    wrist    joint     ••....   291 

156.  Blocking  nerves  for  operations  on   the  thumb    292 

157.  Blocking  nerves  for  operations  on  the  thumb    293 

158.  Blocking   of   the   nerves    above   elbow    294 

159.  Injection    for   operations   on   the    olecranon    process    295 

1 60.  Plexus  blocking  according  to  Kulenkampf   296 

161     .Plexus  blocking   according   to    Kulenkampf    298 

162.  Plexus   blocking  according   to   Kulenkampf    298 

163.  Infiltration    for    ingrowing    nails     299 

164.  Infiltration    for    ingrowing    nails    300 

165.  Infiltration    for    ingrowing    nails    300 

166.  Blocking    for    amputations    of    the    toes    301 

167.  Infiltration    for    Hallux.    Valgus    304 

1 68.  Infiltration    for    Hallux    Valgus    304 

1 69.  Infiltration    for    Hallux    Valgus 305 

170.  Line   of  infiltration   for   operations   on   the   tendo  achillis    306 

171.  Infiltration    for    removal    of    varicose    veins    307 

172.  Injection    for    removal    of    varicose    ulcers     308 

173.  Infiltration    for   operations   on    prepatellar   bursae    311 


CHAPTER  I 
DRUGS  EMPLOYED 

Surgeons  who  use  local  anesthesia  have  long  searched  for  a 
drug  that  would  be  efficient  and  yet  safe  in  any  amount,  but 
such  a  one  has  not  yet  been  discovered.  There  are,  however, 
several  the  dangers  of  which  can  be  avoided,  and  some  that  are 
perfectly  safe  and  efficient  if  used  with  judgment  and  discretion. 
The  former  group  is  represented  by  cocain,  the  first  drug  widely 
used,  which  is  eminently  efficient  but  sometimes  causes  ill  effects 
in  surprisingly  small  quantities.  Novocain,  which  is  equally  effi- 
cient when  used  by  injection  and  much  less  toxic,  has  come  to 
replace  cocain  for  this  purpose.  In  quinine  and  urea  hydro- 
chloride  we  have  a  drug  which  is  entirely  safe  in  any  amount 
and  is  efficient  when  properly  employed.  Experience  is  required 
to  get  as  good  results  from  it  as  from  cocain  and  novocain,  and 
in  some  conditions  it  is  less  easily  employed  than  either  of  them. 
By  the  judicious  selection  of  the  drug  best  suited  for  the  pur- 
pose at  hand  any  condition  may  be  safely  and  effectively  met. 
These  substances  will  be  discussed  seriatim  together  with  a  num- 
ber of  less  used  drugs. 

COCAIN. — On  account  of  its  dangers  the  use  of  this  drug  by 
injection  has  been  almost  discarded,  but  it  is  still  extensively 
used  by  topical  application.  The  danger  can  be  reduced  to  a 
minimum  if  its  application  is  limited  to  the  area  to  be  operated 
upon,  as  in  eye  work,  and  if  it  can  be  injected  directly  into  the 
nerve  sheath,  for  which  purpose  a  very  small  amount  suffices, 
its  action  is  safe,  speedy  and  certain. 

EXTERNAL  APPLICATION. — All  mucous  surfaces  may  be  anes- 
thetized by  the  application  of  cocain.  For  operations  about  the 
eye  and  nose  this  means  of  anesthesia  is  almost  universally  em- 
ployed, and  because  of  the  small  amount  required  in  these  re- 


2  Surgical   Operations  with   Local  Anesthesia 

gions  cocain  is  comparatively  safe.  It  is  more  dangerous  when 
used  about  the  genito-urinary  organs  and  rectum  because  the 
extensive  surfaces  require  more  of  the  solution.  Numerous 
fatalities  have  followed  its  use  in  these  regions,  and  few  opera- 
tors at  the  present  time  care  to  risk  its  use. 

STRENGTH   OF  SOLUTION. — For  local  applications,   particular! 
about  the  eye  and  nose,  a  4  per  cent,  solution  is  most  frequently 
used.    In  the  nose  a  solution  half  that  strength  gives  a  very  sat- 
isfactory   anesthesia,    particularly    when    combined    with    epine 
phrin,  and  is  preferable  on  account  of  greater  safety.    In  the  eye, 
stronger  solutions,  up  to  10  or  even  20  per  cent.,  are  sometime; 
employed,  and  because  of  the  small  amount  absorbed  they  are 
relatively  safe ;  but  they  are  probably  unnecessary  since  weaker 
solutions  give  perfect  anesthesia  if  properly  used. 

METHODS  OF  USE. — A  weak  solution  thoroughly  applied  usually 
gives  a  better  result  than  a  stronger  one  used  timidly  because  of 
anticipated  danger.  With  either  weak  or  strong  solutions,  all 
surfaces  to  be  anesthetized  must  be  touched  and  time  must  be 
allowed  for  absorption  to  take  place.  The  conjunctiva  is  effec.- 
ually  anesthetized  by  dropping  the  solution  into  the  eye  with  a 
medicine  dropper.  A  4  per  cent,  solution  dropped  into  the  eye 
4  or  5  times  at  intervals  of  two  or  three  minutes  usually  gives 
complete  anesthesia.  Care  must  be  taken  that  it  is  allowed  to 
come  in  contact  with  the  entire  surface  to  be  operated  upon.  In 
local  operations,  as  for  the  removal  of  a  tumor,  it  may  be  ad- 
vantageous to  apply  the  solution  with  a  pledget  of  cotton.  In 
the  nose  the  anesthetic  may  be  introduced  by  means  of  a  s., 
or  with  a  pledget  of  cotton.  The  former  is  the  more  convenient 
method  inasmuch  as  all  regions  of  the  nose  can  be  easily  and 
quickly  reached,  but  the  latter  is  more  certain  because  the  drug 
can  be  allowed  to  act  upon  the  exact  spot  until  the  desired  degrp- 
of  anesthesia  is  obtained.  Many  rhinologists  apply  to  the  u^,. 
of  operation,  after  a  cleansing  spray,  a  pledget  of  cotton  wJ"'~1 
has  been  dipped  first  into  epinephrin  solution  and  then  into  pu\\ 
dered  cocain.  When  a  local  anesthetic  is  applied  to  a  mucous 


Surgical   Operations  zvith  Local  Anesthesia  3 

surface  it  must  be  remembered  that  a  secretion  may  be  excited 
which  tends  to  dilute  the  fluid  used.  The  mucus  may  form  a 
viscid  coating  over  the  cotton  which  prevents  further  diffusion  of 
the  anesthetic.  For  this  reason  the  cotton  pledget  should  be 
^-cquently  changed.  The  spray  gives  sufficient  anesthesia  for 
ihe  parts  which  are  not  directly  attacked  in  the  operation  and  is 
useful  in  inhibiting  the  irritability  of  the  mucosa  should  it  be 
touched  during  the  operation.  It  is  usually  desirable,  therefore, 
in  extensive  operations  to  combine  these  methods. 

It  is  hardly  possible  for  enough  of  the  chemical  to  be  absorbed 
from  the  eye  to  give  constitutional  symptoms,  but  in  the  nose 
this  danger  is  always  present,  though  it  can  be  minimized  by 
using  weaker  solutions  and  limiting  the  quantity.  It  is  likely 
that  intoxication  has  resulted  in  most  cases  from  an  excess  of 
solution  which  flowed  into  the  pharynx  and  not  from  absorption 
from  the  nasal  mucosa.  In  the  use  of  the  spray  only  enough  to 
moisten  the  mucous  membrane  of  the  nose  should  be  used.  If 
the  spray  continues  until  the  fluid  runs  into  the  pharynx  the  dan- 
^er  of  absorption  is  greater  and  there  is  no  corresponding  in- 
crease in  efficiency.  In  applying  the  stronger  solution  by  means 
of  a  cotton  pledget  the  excess  of  fluid  should  be  pressed  out  be- 
forehand in  order  to  avoid  its  escape  into  the  pharynx.  The 
pledget,  too,  should  be  no  larger  than  necessary  to  cover  the  field 
of  operation.  With  the  very  strong  solution  (10  to  20  per  cent.) 
recommended  by  some  rhinologists  for  special  purposes,  consti- 
tutional effects  of  an  alarming  character  may  be  produced, 
t-ese  strong  solutions  should  be  used  only  in  individuals  in 
•horn  it  is  known  from  previous  use  of  weaker  solutions  that  no 
idiosyncrasy  exists. 

BY  INJECTION. — Because  of  the  slow  rate  of  absorption  from 
surfaces  other  than  mucous  membranes  it  is  necessary  to  inject 
viie  anesthetic  beneath  the  surface  in  order  to  bring  it  into  con- 
*'  -t  with  the  nerve  endings.  Since  one  must  expect  complete 
ausorption,  the  amount  used  should  not  exceed  the  safe  maxi- 
mum of  y$  gr. 


4  Surgical   Operations  zvith   Local  Anesthesia 

STRENGTH  OF  SOLUTION. — When  cocain  was  first  used  as  a 
local  anesthetic,  4,  5  or  even  10  per  cent,  solutions  were  common- 
ly employed  and  a  number  of  fatalities  resulted.  These  high 
percentages  are  no  longer  used.  A  I  per  cent,  solution  pro- 
duces quite  as  efficient  an  anesthesia  with  proportionately  less 
danger.  To  Schleich  belongs  the  credit  of  having  worked  out 
a  plan  whereby  very  much  weaker  solutions  can  be  used.  He 
employed  solutions  as  weak  as  i-iooo.  In  order  to  enhance  the 
anesthetic  effect  of  the  cocain  he  combined  it  with  morphine  in 
small  amounts  and  sodium  chloride  in  0.2  per  cent,  solution.  In 
a  series  of  experiments  he  determined  that  if  used  in  large  quan- 
tity these  substances  give  a  fair  degree  of  anesthesia  with  safety. 
His  method  causes  an  artificial  edema  in  which  the  pressure 
upon  the  nerves  and  their  endings  aids  very  materially  in  the 
production  of  the  anesthesia.  The  following  formulas  are  those 
recommended  by  Schleich : 

1.  Cocain  Hydrochlorat    0.2     3  gr. 

Morphine   Hydrochlorat    0.02  l/$   gr. 

Sodium   Chloride    (sterilized) 0.2     3   gr. 

Aq.  Best 100.0  3^  oz. 

2.  Cocain  Hydrochlorat   o.i   1^3  gr. 

Morphine  Hydrochlorat  0.02  YJ,  gr. 

Sodium   Chloride    0.2     3  gr. 

Aq.  Best 100.0  3^/3  oz. 

3.  Cocain  Hydrochlorat    o.oi     ]/&  gr. 

Morphine  Hydrochlorat   0.005  I~12  gr- 

Sodium  Chloride 0.2     3  gr. 

Aq.  Best 100.0  3^3  oz. 

METHODS  OF  USE. — In  superficial  operations  cocain  may  be  used 
by  endermic  infiltration.  In  strengths  of  y2  to  i  per  cent. 
it  is  efficient  in  small  quantity  and  may  be  used  either  with  or 


Surgical   Operations  u'ith   Local  Anesthesia  5 

without  epinephrin  for  small  operations,  particularly  in  plastics 
about  the  eye.  Anesthesia  is  complete  as  soon  as  blanching  of 
the  skin  appears.  It  may  be  used  by  direct  injection  into  the 
shafts  of  nerves  as  in  Cushing's  operation  for  hernia.  Some 
operators  use  submucous  injections  as  a  supplement  to  topical 
application  in  intranasal  operations. 

Anesthesia  by  edematization  with  cocain  solutions,  as  intro- 
duced by  Schleich,  consists  in  the  use  of  large  amounts  of  weak 
solutions.  The  anesthetic  effect  is  produced  perhaps  as  much  by 
pressure  and  by  the  0.2  per  cent,  salt  which  it  contains,  as  by 
the  cocain  itself,  particularly  in  the  No.  3  formula.  The  No.  2 
solution  of  Schleich  is  usually  employed  wrhen  large  areas  of 
slightly  sensitive  tissue  are  to  be  injected.  A  syringe  holding  sev- 
eral drams  is  most  convenient.  Matas  has  employed  a  special 
apparatus  operated  by  compressed  air.  A  large  amount  of  the 
solution  is  injected  into  the  region  of  the  proposed  operation  so 
as  to  produce  a  veritable  edema.  The  more  tense  the  edema,  the 
more  perfect  the  anesthesia.  It  is  safe  to  use  in  this  manner  two 
ounces  of  solution  No.  2  and  a  pint  of  solution  No.  3.  This 
method  is  effectual  and  simple,  and  is  extensively  used.  It  has 
the  advantage  of  being  applicable  where  the  exact  distribution 
of  the  nerves  is  not  known.  The  tissue  so  infiltrated  admits  of 
rougher  handling,  which  is  of  advantage  to  the  operator  of  lim- 
ited experience.  The  distension  produced  by  the  edema  some 
operators  find  objectionable,  and  it  certainly  is  undesirable 
where  identification  or  exact  coaptation  of  structure  is  of  im- 
portance, as  in  hernia  operations.  In  certain  operations,  as  in 
enucleation  of  encapsulated  tumors,  this  edema  may  be  a  posi- 
tive advantage. 

ACTION  UPON  THE  TISSUES. — When  applied  to  mucous  surfaces 
it  at  once  produces  blanching  of  the  surface  without  preliminary 
burning  or  dilatation  of  the  vessels.  It  causes  no  pain  when  in- 
jected into  the  tissues  unless  it  is  done  very  bruskly  so  as  to 
cause  tearing  of  the  tissue  before  anesthesia  can  take  place. 
The  healing  process  is  delayed  about  an  hour,  after  which 


6  Surgical   Operations  with  Local  Anesthesia 

it  proceeds  in  the  usual  way.  The  effect  on  wound  healing  is 
therefore  of  purely  theoretical  interest. 

TOXICOLOGY. — A  word  as  to  dangers  or  fatal  results  from  very 
small  amounts  of  cocain  may  not  be  amiss  in  this  place.  Ten 
drops  of  4  per  cent,  solution  used  hypodermically  have  produced 
death.  Eight  drops  of  a  2  per  cent,  solution  produced  violent 
'symptoms  in  a  girl  of  12,  and  4  minims  of  a  3^  per  cent,  solu- 
tion produced  convulsions  followed  by  mania  in  a  strong  man. 
These  instances  are  sufficient  to  show  that  very  minute  quanti- 
ties may  produce  alarming  symptoms. 

In  many  instances  in  which  toxic  symptoms  occur  it  is,  of 
course,  impossible  to  estimate  the  amount  of  drug  actually  ab- 
sorbed. Because  of  this  uncertainty  the  amount  used  should 
not  exceed  that  which  may  safely  be  thrown  into  the  circulation, 
notwithstanding  the  employment  of  methods  intended  to  limit 
its  absorption,  such  as  prompt  incision,  the  use  of  constricting 
bands,  the  addition  of  epinephrin,  etc.  Wood  recommends  that 
a  total  of  three-quarters  of  a  grain  be  not  exceeded  and  that  no 
more  be  used  locally  upon  mucous  membranes  than  would  be 
used  by  hypodermic  injection.  If  these  amounts  are  not  exceed- 
ed unpleasant  results  will  rarely  ensue. 

The  symptoms  of  cocain  poisoning  manifest  themselves  with- 
out warning.  They  are  pallor  or  slight  cyanosis,  often  with 
restlessness  and  sometimes  with  a  sense  of  impending  disaster. 
More  rarely  sudden  collapse  is  the  first  symptom.  These  condi- 
tions may  extend  into  unconsciousness. 

In  some  instances  fainting  may  follow  the  sight  of  blood  or  the 
thought  of  the  operation  may  cause  the  patient  to  become  pale, 
which  may  excite  in  the  mind  of  the  operator  the  fear  of  cocain 
intoxication.  To  distinguish  between  the  two  conditions  is  not 
always  easy.  In  simple  syncope  the  subject's  condition  rarely 
assumes  any  other  form  than  pallor,  limpness  and  loss  of  con- 
sciousness. If  cyanosis,  dyspnoea  and  a  sense  of  fear  or  great 
excitement  appear  it  is  safest  to  assume  that  cocain  intoxication 
has  taken  place. 


Surgical   Operations  with   Local  Anesthesia  7 

The  treatment  of  cocain  poisoning  is  principally  prophylactic. 
Not  much  can  be  done  after  symptoms  appear.  The  patient 
should,  of  course,  be  laid  down  if  not  already  recumbent,  the 
clothing  loosened  and  the  respiratory  action  freed  as  much  as 
possible  from  impediment.  Strychnine  in  small  doses  may  be 
used,  although  its  value  is  questionable.  Morphine,  except  for 
delirium,  is  of  no  use.  When  employed  before  the  cocain  is 
used  it  appears  to  have  a  certain  prophylactic  effect.  For  convul- 
sions, chloroform  may  be  used.  Ether,  administered  by  the  drop 
method,  on  a  mask  has  recently  been  tried  and  is  believed  to 
have  a  direct  antidotal  effect  (J.  E.  Engstadt,  Jour.  A.M.A.  1910, 
March  19). 

QUININE: — SALTS  EMPLOYED. — All  the  soluble  salts  of  quinine 
act  as  local  anesthetics  when  brought  into  contact  with  nerve 
endings  or  nerve  trunks.  I  have  employed  quinine  and  urea 
hydrochloride  almost  exclusively  in  my  operative  work  and  chief- 
ly in  my  experimental  researches.  According  to  Schaefer  (The 
Druggists'  Circular,  Feb.,  1910),  this  salt  is  a  combination  of  one 
molecule  of  quinine  hydrochloride  and  one  molecule  of  urea 
hydrochloride.  The  preparations  upon  the  market  are  the  pow- 
dered crystals  and  the  tablets.  It  is  soluble  in  an  equal  quantity 
of  water  forming  a  strongly  acid  solution.  Quinine  and  urea 
hydrochloride  has  been  used  chiefly  because  of  its  ready  solubil- 
ity and  because  it  is  easily  obtained.  Other  soluble  salts  of  qui- 
nine are  equally  efficient.  Some  of  the  insoluble  salts  will  dis- 
solve if  faintly  acidified,  and  can  then  be  used  with  good  effect. 
A  knowledge  of  this  simple  fact  is  sometimes  of  value  when  other 
means  of  producing  anesthesia  are  not  available. 

ACTION  UPON  THE  TISSUES. — A  study  of  the  action  of  quinine 
upon  the  tissues  is  of  interest  because  certain  of  the  changes 
which  occur  are  liable  to  misinterpretation. 

When  a  soluble  salt  of  quinine  is  injected  into  the  tissues  it 
causes  an  exudate  which  is  at  first  amorphous,  but  which,  if  the 
solution  remains  confined  in  the  tissues,  soon  coagulates  forming 
granular  fibrin.  The  coagulation  begins  after  a  few  minutes  and 


8  Surgical   Operations  zvith  Local  Anesthesia 

is  complete  in  from  12  to  24  hours.  The  skin  so  infiltrated  is 
thickened  and  has  a  reddish  color,  so  that  it  suggests  a  cellular 
infiltration.  It  is  not  tender  to  touch  as  would  be  the  case  in  an 
inflammatory  reaction,  and  sections  show  no  round  cells.  The 
fibrin  occupies  the  spaces  among  the  connective  tissue  fibrils,  dis- 
placing them  but  leaving  them  for  the  most  part  unchanged.  In 
the  midst  of  such  fibrin  the  connective  tissue  fibres  seem  to  lose 
their'  specific  tinctorial  reaction  to  a  slight  degree  but  much  less 
than  in  reactive  processes  of  like  extent.  This  granular  fibrin 
is  not  replaced  by  adult  fibrous  tissue  as  is  the  fibrillar  type  of 
fibrin,  as  described  in  another  place,  but  is  absorbed  after  one 
or  two  weeks  and  the  tissues  resume  the  state  in  which  they 
were  before  the  infiltration  was  made. 

When  quinine  solution  is  injected  into  the  nerve  sheaths  the 
action  is  similar.  Granular  fibrin  forms  among  the  nerve  fibres, 
displacing  and  compressing  them,  but  producing  no  apparent 
changes  in  the  fibres  themselves.  This  observation  is  of  interest 
because  it  indicates  that  the  solutions  are  harmless  when  injected 
into  mixed  nerves  for  the  relief  of  pain.  The  exudate  produced 
by  the  action  of  quinine  upon  the  tissues  has  been  referred  to  as 
an  edema.  This  is  incorrect  because  it  is  spontaneously  coag- 
ulable  and  forms  a  substance  capable  of  reacting  to  specific  fibrin 
dyes.  Furthermore,  in  the  presence  of  a  true  edema,  a  tissue 
is  incapable  of  making  the  first  step  toward  wound  repair.  The 
exudate  produced  by  quinine,  on  the  other  hand,  is  itself  a  first 
step  toward  repair,  although  a  misdirected  one.  This  tendency 
of  quinine  to  produce  an  exudate  is  not  to  be  looked  upon  as 
necessarily  pernicious,  although  it  may  do  harm  if  improperly 
employed.  On  the  other  hand,  if  used  with  intelligence  and  care 
it  can  be  made  to  meet  almost  any  demand  upon  local  anesthesia. 

The  importance  of  keeping  these  changes  in  mind  is,  in  part, 
that  the  reddened  infiltrated  condition  of  the  skin  will  not  be 
thought  due  to  an  inflammatory  reaction.  Much  more  important, 
however,  is  the  fact  that  a  knowledge  of  the  method  of  action  of 
the  drug  enables  one  to  use  it  much  more  intelligently  and  ef- 


Surgical   Operations   with  Local  Anesthesia  9 

f actively.  If  the  skin  is  injected  and  at  once  incised  the  quinine 
solution  escapes  into  the  wound  and  the  fibrin  formation  de- 
scribed above  takes  place  to  a  slight  degree  only ;  anesthesia  lasts 
for  some  hours  only  and  wound  healing  occurs  as  though  no  local 
anesthetic  had  been  used.  This  is  the  result  to  be  aimed  at  in 
skin  incisions  where  a  short  anethesia  and  prompt  healing  of 
the  wound  are  desired.  If,  on  the  other  hand,  primary  union  is 
not  possible  and  prolonged  anesthesia  is  desirable,  it  is  important 
that  the  solution  be  allowed  to  remain  in  the  tissue  as  long  as 
possible  in  order  that  the  exudate  which  later  forms  the  granu- 
lar fibrin  may  appear.  The  pressure  exerted  by  this  exudate 
prevents  the  oozing  which  follows  certain  wounds,  and  limits 
the  hemorrhage  of  the  operation  itself  to  a  degree  depending 
upon  the  amount  of  exudate,  which  in  turn  depends  upon  the 
solution  used  and  the  length  of  time  it  is  allowed  to  remain  in 
the  tissue.  When  infiltration  with  granular  fibrin  takes  place 
anesthesia  lasts  from  several  days  to  two  weeks  or  longer.  This 
is  a  very  desirable  effect  when  primary  union  is  not  to  be  secured 
and  when  pain  following  operation  is  a  prominent  feature,  as  in 
operations  about  the  anus,  in  the  opening  of  abscesses  and  in  less 
degree  in  operations  about  the  throat. 

In  order  to  use  quinine  with  satisfaction  these  actions  of  the 
drug  must  be  kept  in  mind.  That  degree  of  reaction  which  is 
most  desirable  for  the  requirements  of  the  given  case  may  nearly 
always  be  obtained.  The  action  of  quinine  may  be  modified  by 
the  addition  of  epinephrin.  This  substance  by  virtue  of  its  vaso- 
constrictor action  lessens  the  preliminary  dilatation  of  the  capil- 
laries produced  by  the  quinine.  The  exudate  is  lessened  and  the 
duration  of  the  anesthesia  is  correspondingly  shorter.  By  alter- 
ing the  amount  of  epinephrin  I  have  been  able  to  vary  the  dura- 
tion of  anesthesia  in  experiments  on  myself  from  two  hours  to 
several  days. 

EXTERNAL  APPLICATION. — Quinine  has  not  been  as  extensively 
used  by  topical  application  as  it  deserves.  It  acts  less  promptly 
than  cocain,  it  is  true,  but  it  is  of  value  on  account  of  its  absolute 


io  Surgical   Operations  with  Local  Anesthesia 

safety  and  prolonged  effect.  It  is  more  efficient  applied  locally 
than  novocain  and  is  much  cheaper.  Late  oozing  is  less  likely  to 
occur  than  after  cocain ;  it  is  rarely  necessary  to  pack  to  prevent 
oozing  after  nasal  operations  when  quinine  has  been  used.  I 
employ  quinine  universally  in  nasal  work  and  never  fail  to  secure 
anesthesia.  Because  of  its  irritating  effect  quinine  is  not  desira- 
ble for  use  in  the  eye. 

STRENGTH  OF  SOLUTION. — In  strengths  of  5  per  cent,  to  io  per 
cent,  local  anesthesia  may  be  secured  in  mucous  membranes  by 
topical  application.  For  making  these  stronger  solutions  pow- 
dered crystals  are  preferable  to  tablets,  although  the  latter  are 
usually  employed  because  of  their  convenience. 

METHODS  OF  USE. — The  nose  is  the  most  frequent  place  for  the 
local  use  of  quinine.  It  is  applied  upon  pledgets  of  cotton  as 
described  for  cocain.  Any  desired  amount  may  be  used.  The 
duration  of  the  anesthesia  may  be  in  great  measure  controlled  by 
the  length  of  time  the  anesthetic  is  allowed  to  remain  in  contact 
with  the  mucous  surface.  When  applied  for  acute  coryza  or  hay 
fever  where  the  longest  possible  action  is  desired,  it  should  be 
allowed  to  remain  for  15  to  30  minutes,  while  as  a  preliminary 
to  therapeutic  applications  a  shorter  time  will  suffice.  For  de- 
structive applications  or  operations  the  longer  period  is  required. 
Because  of  the  bitter  taste  of  the  drug,  care  to  prevent  its  run- 
ning into  the  mouth  will  be  appreciated  by  the  patient,  for  as 
Brewster  remarked  "They  complain  of  the  taste  bitterly," 

The  action  of  quinine  when  applied  to  mucous  surfaces  is  to 
produce  first  a  slight  burning  sensation,  and  then  an  increased 
production  of  mucus.  Frequent  changes  of  the  pledgets  is  even 
more  necessary  than  when  cocain  is  used  because  the  initial  ir- 
ritation is  greater.  Pledgets  as  large  as  can  be  introduced  should 
be  employed  so  that  the  entire  area  likely  to  be  touched  by  the 
manipulations  comes  in  contact  with  them.  Too  great  pressure, 
however,  will  lessen  capillary  activity  and  delay  absorption.  The 
pledgets  should  be  changed  at  least  three  or  four  times. 

After  anesthesia  has  been  secured  a  certain  degree  of  shrink- 


Surgical   Operations  with  Local  Anesthesia  n 

ing  of  the  tissue  may  be  secured  by  using  pledgets  saturated 
with  epinephrin  solution.  This  facilitates  the  operation  and  does 
not  interfere  with  the  anesthesia.  The  degree  of  retraction  of 
tissue  is  by  no  means  equal  to  that  produced  by  cocain-epine- 
phrin  solution,  so  that  quinine  has  somewhat  less  immediate  ad- 
vantage where  hemorrhage  is  annoying,  as  in  work  on  the  sep- 
tum. On  the  other  hand,  because  of  the  absence  of  late  oozing 
and  after-pain,  quinine  is  indicated  in  turbinectomies  and  other 
operations  where  delicate  manipulations  are  not  required. 

The  urinary  bladder  may  be  satisfactorily  anesthetized  by  the 
use  of  quinine.  Any  amount  may  be  safely  used,  and  it  may  be 
allowed  to  remain  in  contact  for  any  desired  length  of  time. 
Further  experimentation  will  be  required  before  it  can  be  deter- 
mined exactly  what  reliance  can  be  placed  upon  the  drug  for  this 
purpose.  I  have  found  sacral  blocking  so  much  more  effective 
that  I  no  longer  employ  topical  application  preliminary  to  in- 
travesical  manipulations  and  but  seldom  as  a  preliminary  to 
operations  on  the  bladder. 

BY  INJECTION. — Quinine  has  been  used  most  extensively  by 
injection.  It  is  more  likely  than  cocain  to  cause  burning  when 
first  injected,  but  this  lasts  only  a  few  seconds  and  can  usually 
be  entirely  prevented  by  slow  injection.  A  few  trials  in  the 
operator's  own  skin  will  teach  him  the  need  and  the  art  of  gen- 
tleness. 

STRENGTH  OF  SOLUTION. — Quinine  being  safe  in  any  strength, 
one  need  consider  only  the  amount  of  the  drug  that  is  necessary 
to  produce  the  desired  results.  An  extended  use  has  proven  that 
a  i  per  cent,  solution  is  sufficient  to  produce  anesthesia  under 
all  conditions.  Weaker  solutions,  y^  per  cent,  or  even  34  Per 
cent.,  give  efficient  anesthesia  if  skillfully  used.  When  temporary 
anesthesia  only  is  desired,  and  primary  union  with  a  minimum 
amount  of  scarring  is  important,  as  in  operations  about  the  face, 
and  in  loose  tissue  containing  few  nerves,  these  weaker  solu- 
tions are  to  be  preferred.  Where  prolonged  anesthesia  is  de- 
sired as  in  nearly  all  extensive  operations,  or  where  the  tissue 


12  Surgical   Operations  with  Local  Anesthesia 

is  involved  in  a  reactive  irritation,  the  stronger  solution  is  pre- 
ferable. I  have  never  seen  the  advantage  of  the  strong  solu- 
tions recommended  by  Brown  (3  per  cent.),  though  in  certain 
situations  they  are  not  particularly  objectionable.  The  solution 
should  be  made  fresh  just  before  using.  For  ordinary  use  two 
2-grain  tablets  may  be  dissolved  in  i  oz.  of  water  and  the  solu- 
tion boiled.  This  makes  approximately  a  4-5  per  cent,  solu- 
tion. I  use  this  strength  for  all  routine  work.  Instead  of  a 
watery  solution  normal  salt,  or  a  i  or  2  per  cent.  Ca  Cl  2  may 
be  used  as  the  solvent. 

METHODS  OF  USE. — Quinine  has  found  its  most  extensive  use 
in  endermic  infiltration  and  for  nerve  blocking  when  the  nerve 
can  be  directly  injected,  as  during  amputation.  Where  much 
after-pain  is  expected  or  where  the  cautery  is  used  it  is  of  par- 
ticular value  and  is  preeminently  the  anesthetic  of  choice,  but 
may  be  used  in  any  operation.  Failure  to  secure  anes- 
thesia is  due  to  faulty  technic.  Necrosis  following  its  use 
is  due  to  massive  injections  and  can  always  be  avoided  by 
proper  care.  After  an  extended  experience  with  quinine  I  have 
yet  to  see  necrosis  result  from  its  use  during  an  operation,  ex- 
cept in  one  case,  in  which  after  the  removal  of  a  wart  situated 
close  to  the  nail-bed  the  tissue  between  the  incision  and  nail  be- 
came necrotic. 

I  produced  necrosis  experimentally  in  the  skin  of  my  leg  by 
injecting  two  cc  of  a  i  per  cent,  solution  at  the  same  point  un- 
der firm  pressure.  After  a  few  days  an  area  the  size  of  a  dime 
became  black,  and  after  two  weeks  separated  leaving  an  ulcer 
which  required  three  months  to  heal.  I  can  testify  to  the  fact, 
therefore,  that  it  is  possible  to  produce  necrosis  of  tissue  with 
quinine,  but  it  can  be  done  only  by  employing  such  an  amount  of 
fluid  introduced  under  such  a  pressure  as  is  never  required  in 
practice. 

Quinine  is  employed  for  infiltration,  for  nerve  blocking  or 
for  perineural  blocking,  which  is  a  modification  of  nerve  block- 
ing. It  is  rarely  used  for  edematization ;  first,  because  it  is  unnec- 


Surgical   Operations  with   Local  Anesthesia  13 

essary  for  the  production  of  anesthesia;  and,  second,  it  is  unde- 
sirable, because  when  quinine  is  thrown  into  the  tissues  the  fi- 
brinous  exudate  previously  described  may  be  formed  in  large 
amounts.  This  produces  a  swelling  which  lasts  for  a  week  or 
longer,  and  while  it  results  in  no  permanent  mischief  it  calls  forth 
expressions  of  curiosity  or  alarm  from  the  patient.  These  ob- 
jections apply,  let  it  be  understood,  only  when  large  amounts,  as 
several  ounces,  are  injected  into  the  loose  cellular  tissues.  There 
are  a  few  instances  in  which  edematization  with  quinine  is  de- 
sirable. These  will  receive  specific  mention  in  the  discussion  of 
those  operations  where  it  is  to  be  recommended. 

RAPIDITY  OF  ACTION. — As  soon  as  the  endermic  infiltration  is 
completed  the  operation  may  begin,  unless  perineural  blocking 
is  depended  upon  for  a  part  of  the  field,  in  which  case  anesthesia 
is  sometimes  not  complete  for  10  or  more  minutes.  It  is  my  prac- 
tice not  to  delay  the  operation  at  any  stage  for  the  purpose  of 
permitting  the  anesthetic  to  act,  but  to  continue  leisurely  without 
interruption.  By  a  little  foresight  it  is  possible  to  occupy  the 
time  as,  for  instance,  in  making  ligatures,  while  some  recently 
injected  or  slowly  working  area  is  being  influenced  by  the  anes- 
thetic. Where  prolonged  anesthesia  is  desired  to  prevent  post- 
operative oozing,  the  solution  should  be  allowed  to  remain  in 
contact  with  the  tissue  in  order  that  the  fibrinous  exudate  may 
form  before  the  operation  is  begun.  This  is  well  established  in 
a  period  varying  from  twenty  to  thirty  minutes,  and  becomes 
much  more  complete  if  many  times  the  period  mentioned  is  al- 
lowed to  elapse  before  the  operation  begins. 

TOXICOLOGY. — Closson  raises  the  question  of  the  safety  of  qui- 
nine because  he  found  it  toxic  to  guinea  pigs.  However,  there 
seem  to  have  been  no  serious  results  from  its  therapeutic  use, 
even  in  large  quantities.  Brewster  used  100  grains  in  one  pa- 
tient for  pernicious  malaria  with  recovery  both  from  the  malaria 
and  the  quinine.  Far  larger  amounts  than  are  ever  required  in 
local  anesthesia  have  been  employed  so  many  thousands  of  times 


14  Surgical   Operations  with  Local  Anesthesia 

without  disastrous  results  that  one  may  consider  quinine  as  safe 
as  a  drug  can  be. 

I  have  encountered  but  one  case  of  idiosyncrasy  in  the  use  of 
quinine  as  an  anesthetic.  In  this  patient  I  used  five  minims  of  a 
I  per  cent,  solution  preliminary  to  the  tapping  of  a  hydrocele. 
The  scrotal  region  and  lower  abdomen  became  covered  with  an 
extremely  annoying  eruption  which  lasted  for  a  day  or  two.  The 
patient  knew  that  he  possessed  a  quinine  idiosyncrasy. 

Necrosis  following  the  use  of  quinine  has  come  to  my  notice 
a  number  of  times  in  the  practice  of  my  associates.  The  most 
distressing  instance  was  the  loss  of  a  toe  following  a  hallux 
va.gus  operation.  Skin  necrosis  lonowmg  trie  removal  of  tumors 
has  occurred  a  number  of  times.  A  rim  of  necrosis  about  the 
foreskin  after  circumcision  is  the  most  common  type  of  mishap. 

These  occurrences  always  result  from  technical  errors.  Be- 
cause the  drug  is  safe  in  any  amount  operators  are  too  prone  to 
use  excessive  amounts  so  as  to  make  certain  of  anesthesia.  It 
is  never  necessary  to  use  enough  to  endanger  the  tissue. 

OTHER  SALTS  OF  QUININE. — A  year  and  a  half  ago  Prof.  J. 
Morgenroth,  of  Berlin,  placed  at  my  disposal  several  new  quinine 
preparations  with  the  request  that  I  study  these  products  histo- 
chemically  and  clinically.  It  has  been  possible  to  date  to  study 
but  one  of  these,  namely,  Isoamylhydrocuprein  hydrochloricum. 

Professor  Morgenroth,  (Berlin,  Klin.  Woch.,  1912,  No.  46  and 
Berlin,  Klin.  Woch.,  1913,  No.  8),  has  made  a  study  of  this  and 
other  preparations  on  the  cornea.  He  states  that  this  drug  is 
twenty  times  the  strength  of  quinine  and  is  efficient  in  o.i  to 
0.125  Per  cent,  solutions.  In  this  strength  an  efficient  anesthesia 
lasting  forty  hours  was  produced.  In  stronger  solutions,  0.25  per 
cent.,  some  clouding  of  the  cornea  of  the  rabbit  resulted  and  in 
still  stronger  solutions  chemosis  occurred. 

I  have  employed  this  drug  in  i-io  per  cent,  solutions  both  in 
plain  water  and  in  normal  salt.  The  action  histochemically  and 
as  an  anesthetic  is  about  equal  to  quinine  and  urea  hydrochloride 


Surgical   Operations  tvith  Local  Anesthesia  15 

of  ten  times  this  strength.  My  experiments  have  not  yet  been 
terminated  and  my  clinical  experience  with  it  is  limited. 

NOVOCAIN. — Braun  (Deutsch.  med.  Woch.,  1905,  xxxi,  1667; 
Beitr.  z.  Klin.  Chir.,  1909,  LXII,  641),  has  contributed  much  to 
the  advancement  of  local  anesthesia  by  introducing  the  use  of 
novocain  with  epinephrin.  This  combination  has  become  the 
most  widely  used  substance  for  the  production  of  local  anesthe- 
sia. Used  by  injection  it  is  as  efficient  as  cocain  and  much  safer. 
It  is  stated  that  it  is  seven  times  less  toxic  than  cocain  and  that 
fewer  persons  possess  a  susceptibility  toward  it.  Cases  have 
been  reported  where  tonic  and  clonic  spasms  were  produced,  but 
no  fatal  cases  have  been  reported.  Because  of  its  slight  irritabil- 
ity and  the  rapidity  of  its  action,  together  with  the  comparatively 
bloodless  operative  field  produced  by  the  added  epinephrin  so- 
lution, this  drug  is  the  most  easily  used  and  generally  efficient 
anesthetic  at  present  available  and  is  to  be  unqualifiedly  recom- 
mended to  the  beginner. 

LOCAL  USE. — Novocain  produces  a  slight  initial  burning  and 
a  dilatation  of  the  capillaries  when  applied  to  mucous  surfaces. 
For  this  reason  it  is  less  serviceable  for  use  in  the  eye  than 
cocain. 

In  the  nose  and  pharynx  it  can  be  used  with  fairly  good  results 
in  ten  per  cent,  solution.  It  acts  more  slowly  than  alypin,  is  more 
expensive  than  quinine,  and  less  efficient  than  either. 

BY  INJECTION. — When  injected  into  the  tissues  novocain  causes 
a  slight  burning  and  an  ephemeral  dilatation  of  the  vessels.  If 
used  alone  the  effect  begins  to  disappear  in  about  15  minutes. 
If  used  with  epinephrin  the  initial  dilatation  does  not  appear  and 
the  anesthesia  is  prolonged  for  an  hour  or  more. 

STRENGTH  OF  SOLUTION. — Ordinarily  a  y2  to  i  per  cent,  solu- 
tion is  used.  To  this  may  be  added  4  to  8  drops  of  i-iooo  epine- 
phrin solution.  For  infiltration  of  the  skin  and  perineural 
blocking  the  I  per  cent,  solution  is  usually  best.  For  infiltrating 
loose  tissue  about  tumors,  the  thyroid  or  a  hernial  sac,  J^  or  even 
Y^  per  cent,  solution  may  be  employed.  The  operator  will  do 


"i 6  Surgical   Operations  with  Local  Anesthesia 

well  to  calculate  in  the  beginning  the  amount  of  fluid  likely  to 
be  required.  In  extensive  operations  the  weaker  solutions  may 
be  used  in  situations  where  in  smaller  operations  the  stronger  so- 
lution would  be  preferred.  Occasionally  in  perineural  blocking, 
as  about  the  deep  nerves  of  the  skull  and  face,  some  operators 
recommend  a  2  per  cent,  solution.  Novocain  bears  boiling.  It 
should  be  boiled  in  physiological  salt  solution  and  the  epinephrin 
added  after  it  has  cooled  to  body  temperature.  Fischer  (Die 
lokale  anesthesie  in  der  Zahnheilkunde;  Meusser,  Berlin,  1911) 
advises  the  addition  of  thymol  both  because  it  is  in  itself  a  local 
anesthetic  and  because  it  acts  as  a  preservative.  His  formula  is 
as  follows : 

Novocain    1.5 

Sodium    Chloride 0.92 

Thymol    O-O25 

Distilled   Water 100.0 

This  makes  a  il/2  per  cent,  solution  of  novocain  in  normal  salt 
to  which  1-3  grain  thymol  has  been  added.  It  bears  boiling  and 
epinephrin  may  be  added  at  the  time  of  use.  For  dentists  or  for 
office  use  where  small  amounts  are  likely  to  be  used  at  all  hours 
of  the  day  this  solution  can  be  highly  recommended.  For  general 
use  it  has  the  slight  objection  that  it  causes  more  burning  when 
introduced  into  the  skin. 

M.  L.  Harris  praises  very  highly  the  addition  of  chlorbutanol 
in  saturated  solution — 8  parts  per  thousand.  He  warns  me  that 
it  must  be  made  just  right  or  it  is  spoiled  in  the  making.  The 
water  is  boiled  long  enough  to  insure  sterility,  20  to  30  minutes. 
The  novocain  is  then  added  and  the  boiling  continued  not  over 
three  or  four  minutes.  It  is  then  removed  from  the  flame  and 
is  cooled  to  below  170  F.  and  the  chlorbutanol  added.  Since 
chlorbutanol  volatilizes  above  170  F.  the  importance  of  the  last 
precaution  is  evident.  Epinephrin  is  added  just  before  using. 


Surgical   Operations  with  Local  Anesthesia  17 

Harris  (Surg.,  Gyn.  and  Obst.,  1915,  xx,  193)  now  uses  a 
solution  of  novocain-epinephrin  to  which  calcium  chloride  in 
from  YA,  to  y>  per  cent,  and  8-10  per  cent,  of  chlorbutanol  is 
added.  He  gives  the  following  directions  for  making  the  solu- 
tion :  the  water  is  sterilized  by  boiling,  after  which  the  novo- 
cain  is  added  and  the  boiling  continued  for  2  or  3  minute? 
longer.  When  this  has  cooled  to  160  degrees  Fahr.  i  per  cent, 
chlorbutanol  is  added.  The  calcium  chloride  solution  is  made 
and  sterilized  and  after  it  has  cooled  the  chlorbutanol  is  added 
the  same  as  to  the  novocain  solution.  By  diluting  the  first  so- 
lution with  the  second  a  varying  percentage  of  novocain  and 
calcium  chloride  is  readily  obtained.  The  epinephrin,  4  or  5 
drops  to  30  cc.  of  the  solution,  is  added  just  before  use. 

Hoffman  and  Kochmann  (Deittsch.  med.  Wochnschr.  1912, 
xxxviii,  2264)  add  2  per  cent,  of  calcium  sulphate  to  the  novo- 
cain solution.  They  claim  that  by  the  addition  of  this  substance 
the  novocain  is  made  more  potent  so  that  solutions  of  i-io  per 
cent,  are  effective.  After-pain  is  said  to  be  lessened.  My  own 
experience  with  this  combination  has  not  been  so  favorable. 

METHOD  OF  USE. — When  injected  about  the  roots  of  nerves 
in  I  per  cent,  solution  it  produces  anesthesia  in  the  region  sup- 
plied by  those  nerves  in  from  15  to  30  minutes.  It  is  non-irrita- 
ting when  so  used  and  the  amount  is  limited  only  by  the  toxicity 
of  the  drug.  For  the  injection  of  such  loose  tissues  as  the  capsules 
about  tumors,  a  weaker  solution  may  be  used,  ^  per  cent,  or  even 
less  if  the  operation  requires  a  large  amount  of  the  solution  as  is 
the  case  in  breast  amputations.  Endermic  infiltration  is  readily 
accomplished  by  I  per  cent,  or  even  ^  per  cent,  solutions. 

ACTIONS  UPON  THE  TISSUES. — Novocain  when  applied  locally 
causes  temporary  dilatation  of  the  superficial  capillaries.  When 
injected  into  the  tissues  it  produces  a  fleeting  hyperemia  asso- 
ciated with  a  moderate  degree  of  burning.  When  used  with 
epinephrin  the  preliminary  hyperemia  does  not  occur  and  the 
burning  can  be  avoided  by  the  injecting  of  the  fluid  slowly. 
Novocain  with  epinephrin,  on  account  of  the  constringent  action 


i8  Surgical   Operations  zvith  Local  Anesthesia 

of  the  latter,  tends  to  delay  wound  healing  more  than  cocain 
does.  This  fact  does  not  seem  to  be  of  much  importance  except 
in  case  of  cleft  palate  operations,  in  which  I  am  convinced  that 
although  novocain-epinephrin  is  valuable  in  reducing  hemor- 
rhage, it  also  lessens  the  chance  of  healing. 

TOXICITY. — No  records  of  fatal  cases  have  been  encountered  in 
the  literature.  Based  upon  the  statement  of  pharmacologists  that 
novocain  is  only  one-seventh  as  toxic  as  cocain,  operators  have 
limited  the  use  to  7  grains  for  the  operation.  Braun  has  used 
double  this  amount  without  bad  results. 

STOVAIN. —  (Braun,  Munch,  med.  Woch.  1905,  LIT,  1177;  Ken- 
dirdjy,  L'anesthesie  chirurgicale  par  la  Stovain.  Paris,  Masseon 
et  Cie.,  1906).  This  drug  has  been  used  chiefly  in  spinal  anes- 
thesia, but  it  has  also  been  used  by  injection.  It  is  less  toxic  and 
less  efficient  than  cocain,  but  is  said  to  give  better  results  in  in- 
flamed tissue.  In  many  cases  it  is  reported  to  work  well  and  in 
others  without  evident  reason  results  are  not  satisfactory.  One 
is  justified  in  regarding  such  statements  as  reflecting  more  on  the 
technic  of  the  surgeon  than  on  the  efficiency  of  the  drug.  Stovain 
may  be  used  in  the  same  way  as  novocain.  It  has  been  added  to 
alcohol  for  injection  into  neuralgic  nerves. 

OTHER  DRUGS  USED. — Because  of  the  well  organized  dangers 
attending  the  use  of  cocain  many  substitutes  have  been  intro- 
duced, but  they  are  all  inferior  in  efficiency,  though  safer.  No- 
vocain has  been  the  most  widely  used  of  these.  Several  others 
have  enjoyed  a  degree  of  popularity  and  may  be  here  enumerated. 

Beta-eucain  may  be  used  in  quantities  up  to  three  grains,  it 
is  said,  and  as  much  as  15  grains  have  been  used  without  alarm- 
ing effects.  It  may  be  used  in  the  same  strength  as  cocain  in 
Schleich  solutions,  or  in  I  per  cent,  solution  for  infiltration.  For 
local  application  in  the  eye  or  nose,  solutions  of  2  per  cent,  are 
used.  Tropacocain  has  been  used  in  similar  strengths,  and  is 
said  to  be  safe  up  to  five  grains.  Among  other  drugs  which  have 
been  used  may  be  mentioned  anesthesine,  subcutln,  and  alypin. 
Of  these  the  last  has  been  much  used,  but  is  inferior  to  cocain. 


Surgical   Operations  zvith  Local  Anesthesia  19 

Pure  water  has  been  made  use  of  by  S.  G.  Gant  in  operations 
about  the  rectum.  It  is  necessary  to  inject  the  tissue  so  tensely 
that  it  becomes  thoroughly  blanched.  The  injection  itself  fre- 
quently causes  acute  pain,  which  may  be  lessened  by  pressing  the 
tissue  as  it  is  being  injected  firmly  between  the  thumb  and  finger. 
This  means  of  securing  anesthesia  has  an  extremely  limited  field 
of  usefulness  and  can  be  recommended  only  for  operations  of 
short  duration  when  other  means  are  not  at  hand. 

SEQUENTIAL  COMBINATION  OF  LOCAL  ANESTHETICS. 1  habit- 
ually employ  novocain-epinephrin  and  quinine  and  urea  hydro- 
chloride  during  the  same  operation,  using  the  one  for  one  part 
of  the  operation,  the  other  for  another  part  of  the  same  opera- 
tion. This  is  done  for  the  purpose  of  employing  that  drug  in 
the  particular  part  of  the  operation  in  which  it  is  particularly 
indicated  and  for  limiting  the  amount  of  the  more  dangerous 
drug  required. 

Thus,  in  rectal  amputations,  quinine  urea  is  used  in  the  skin  and 
the  sensitive  regions  of  the  terminal  segment  of  the  gut  while 
the  novocain-epinephrin  is  used  in  the  loose  para  rectal  tissue  or 
in  sacral  blocking.  In  large  umbilical  hernias  quinine  is  used  in 
the  extensive  infiltration  of  the  skin  and  the  novocain  is  used  in 
the  fascial  and  preperitoneal  tissue.  In  large  goiters,  too,  the 
skin  infiltration  is  made  with  quinine  while  novocain  is  used  for 
the  deeper  tissue.  If  deeper  nerves  are  reached,  as  in  blocking 
the  nerves  of  the  thigh,  quinine  would  be  employed  to  block  the 
nerve,  while  novocain  may  be  used  as  a  matter  of  convenience  in 
the  superficial  tissues.  By  judicious  combinations  of  anesthetics, 
operations  of  almost  any  magnitude  may  be  performed  without 
approaching  a  dangerous  dosage  of  any  one  of  them. 

COMBINATIONS     OF     SEVERAL     LOCAL     ANESTHETICS. Numerous 

attempts  have  been  made  to  enhance  safety  and  efficiency  by 
combining  the  safe  with  the  efficient.  The  only  combination 
worthy  of  trial  is  that  of  quinine  with  novocain-epinephrin.  By 
so  doing  the  quick  action  of  the  novocain,  the  vessel  constricting 
action  of  epinephrin  with  the  prolonged  action  of  quinine  is  ob- 


2O  Surgical   Operations  witli   Local  Anesthesia 

tained  in  part.  The  result  of  this  combination  is  that  the  full 
effect  of  neither  is  attained.  The  constricting  action  of  epine- 
phrin  is  compromised  by  the  quinine  and  the  prolonged  effect  of 
quinine  is  lessened  by  the  epinephrin.  Nevertheless  this  com- 
promise may  be  very  desirable  in  certain  small  operations  where 
a  relatively  bloodless  field  with  control  of  after  pain  is  desired 
as  in  tonsilectomy  and  operations  at  the  mucocutaneous  border 
of  the  anus.  Anesthesia  is  easier  to  attain  by  this  combination 
by  virtue  of  the  novocain,  the  adrenalin  secures  a  measure  of 
anemia  and  the  quinine  controls  the  after-pain  longer  than  where, 
this  drug  is  not  employed. 

The  proportionate  combination  most  useful  depends  upon  the 
use  to  which  it  is  put.  In  tonsilectomies  the  novocain  should  pre- 
dominate, using: 

Novocain    gr.  v 

Quinine  urea  hydrochloride gr.  ii 

Epinephrin    gtt.  viii 

Water    oz.    i 

In  operations  in  the  anal  region  the  following  is  more  desir- 
able: 

Novocain    gr.   v 

Epinephrin    gtt.   vii 

Quinine  urea  hydrochloride gr.  iv 

Water    oz.    i 

This  combination  may  be  employed  for  more  extensive  opera- 
tions where  these  qualities  are  desired,  but  on  the  whole  the  ends 
are  better  served  by  using  that  drug  which  secures  the  definite 
result  desired. 

THE  USE  OF  EPINEPIIRIN  AS  AN  AID  IN  LOCAL  ANESTHESIA. Per- 
haps more  credit  is  due  to  Braun  than  to  anyone  else  for  having 
discovered  the  usefulness  of  epinephrin  as  an  adjunct  to  anes- 


Surgical   Operations  with  Local  Anesthesia  21 

thetic  solutions.  By  means  of  this  drug  he  hoped  to  lessen  the 
rate  of  absorption  of  cocain,  and  render  it  thus  at  once  safer  and 
more  effective.  Its  chief  value  perhaps  is  in  lessening  hemor- 
rhage. When  used  with  novocain  it  also  lengthens  the  duration 
of  anesthesia  from  4  to  10  times.  Sickenburg  denies  that  epine- 
phrin  makes  cocain  either  safer  or  more  efficient.  Usually  from 
5  to  15  drops  of  a  i-iooo  epinephrin  solution  are  added  to  an 
ounce  of  the  anesthetic  solution.  Fischer  believes  that  not  more 
than  7  minims  should  be  used  at  one  operation,  but  the  results 
of  intoxication  are  not  serious.  Palpitation,  cardiac  spasm  and 
dyspnoea  may  appear  early  in  the  operation  but  soon  disappear 
and  do  not  return.  Toxic  symptoms  are  more  apt  to  manifest 
themselves  if  the  solution  is  old,  and  if  it  is  injected  directly  into 
a  vein.  Barker  used  epinephrin  with  beta-eucain  with  great  sat- 
isfaction. It  must  be  admitted  that  addition  of  epinephrin  re- 
duces hemorrhage  and  probably  lessens  the  rate  of  absorption, 
and  thus  increases  the  effectiveness  of  the  anesthetic.  The  ac- 
tion is  but  temporary,  and  it  has  seemed  to  me  that  the  disposi- 
tion to  ooze  when  the  effects  of  the  drug  have  disappeared  is 
greater  than  when  it  has  not  been  used  at  all.  Hematomas  may 
form  after  the  skin  incision  has  been  closed,  or  prolonged  oozing 
may  occur  from  exposed  wounds,  especially  after  operations 
upon  the  nose  and  throat. 

Added  to  the  quinine  solution  epinephrin  has  a  very  interest- 
ing effect  inasmuch  as  it  limits  the  amount  of  fibrin  produced. 
For  this  reason  it  may  be  advantageously  added  for  use  in  re- 
gions where  the  induration  produced  by  quinine  when  used 
alone  is  undesirable.  It  should  be  noted  that  the  duration 
of  anesthesia  is  thereby  much  reduced  and  where  after- 
pain  is  considerable  the  use  of  epinephrin  is  not  advisable 
When  added  to  quinine  it  lessens  the  hemorrhage  and  pre- 
vents in  a  measure  the  primary  dilatation  of  the  vessels 
produced  by  that  drug.  Each  region  and  operation  ha.s 
requirements  peculiar  to  itself,  and  when  modifications  in 
the  solution  are  required  they  will  be  mentioned  in  the  specific 


22  Surgical  Operations  with  Local  Anesthesia 

operations.  Until  the  operator  has  become  expert  in  the  use  of 
quinine  he  should  not  experiment  with  epinephrin. 

EPINEPHRIN. — The  unstable  nature  of  epinephrin  must  be  re- 
membered and  only  fresh  preparations  used.  If  the  anesthetic 
solution,  usually  novocain,  becomes  pink  after  the  epinephrin 
is  added  the  whole  should  be  thrown  away,  and  a  new  solution 
of  novocain  should  be  prepared  and  a  fresh  bottle  of  epinephrin 
secured.  Often  a  fine  granular  deposit  is  formed  in  the  epine- 
phrin solution.  When  this  occurs  it  is  inert  and  a  new  supply 
must  be  secured.  This  granular  deposit  is  most  easily  detected 
by  withdrawing  it  from  the  container  by  means  of  a  medicine 
dropper  and  observing  this  thin  column  by  direct  light. 

COMBINED  LOCAL  AND  GENERAL  ANESTHESIA. — For  a  long  time 

general  anesthesia  has  been  employed  in  particularly  painful 
stages  where  local  anesthesia  is  used  for  the  major  portion  of  the 
anesthetic.  Thus,  a  few  whiffs  of  gas-oxygen  may  be  given  in 
appendectomies  when  the  adhesions  are  being  separated,  or  when 
the  bone  is  being  sawed  or  chiseled  in  jaw  dissection. 

With  the  advent  of  quinine  as  a  local  anesthetic  the  associa- 
tion of  local  and  general  anesthetics  has  found  a  new  application. 
Rogers  first  proposed  (verbal  communication,  1908)  that  when 
operations  are  done  under  general  anesthesia,  those  areas  likely 
to  be  attended  by  marked  after-pain  should  be  injected  with  qui- 
nine for  the  sole  purpose  of  lessening  the  suffering  after  the  pa- 
tient comes  from  under  the  anesthetic,  as  when  hemorrhoids  are 
tied  off  in  the  course  of  a  major  gynecological  operation,  or  when 
hemorrhoids  are  operated  primarily  under  general  anesthesia. 
Likewise  nerves  that  have  been  severed  in  an  amputation  may 
be  injected  in  order  to  limit  the  pain. 

SECONDARY  EFFECTS  OF  LOCAL  ANESTHESIA. — A  commonly  OVCr-- 

looked  accompaniment  of  local  anesthesia  is  the  zone  of  hyper- 
esthesia  about  the  anesthetized  area.  A  space  varying  from  % 
to  Y-2.  inch  or  more  immediately  beyond  the  anesthetized  area 
ordinarily  becomes  excessively  sensitive  to  touch  though  not  to 
pain.  The  cause  of  this  phenomenon  is  not  understood,  but  the 


Surgical  Operations  with  Local  Anesthesia  23 

importance  of  recognizing  it  is  great.  If  it  is  overlooked,  touch- 
ing or  pressure  upon  this  zone  may  cause  acute  suffering  and  the 
operator  may  believe  that  anesthesia  of  the  site  of  injection  is  in- 
sufficient or  has  already  disappeared.  This  hyperesthesia  often 
lasts  a  day  or  two  or  even  longer. 

FREEZING. — The  usefulness  of  freezing  in  producing  anesthesia 
is  very  limited,  and  furthermore  the  thawing  causes  severe  pain 
quite  independent  of  any  pain  which  may  be  attendant  upon  the 
operation  itself.  It  has  a  certain  use,  however,  for  operations  of 
short  duration  upon  the  skin. 


Fig.  1.     Ethyl  chloride  container  for  freezing. 

METHODS. — Cooling  sufficient  to  make  the  skin  insensible  may 
be  secured  by  pressing  salt  against  the  skin  with  a  piece  of  ice,  the 
size  of  a  walnut,  for  a  few  minutes.  This  method  has  been  used 
for  simple  punctures,  as  in  thoracic  paracentesis,  in  the  absence 
of  more  suitable  material.  For  timid  patients  it  has  the  same 
advantage  as  all  methods  of  freezing,  that  anesthesia  can  be  pro- 
duced without  pain.  The  fact  that  the  patient  suffers  more  from 
the  thawing  than  from  the  operation  itself  is  not  a  contraindica- 
tion sufficient  to  prevent  its  use  in  such  persons. 

The  usual  method  of  freezing  is  by  the  use  of  volatile  sub- 
stances. Ether  spray  used  as  with  a  freezing  microtome  may  be 
employed.  Ethyl  chloride  has  been  used  most,  however,  and  is 
the  most  convenient.  It  is  placed  upon  the  market  in  small  con- 
tainers (Fig.  i)  fitted  with  a  cap  or  valve  which  prevents  evap- 


24  Surgical  Operations  with  Local  Anesthesia 

oration  when  not  in  use.  These  containers  are  of  such  size  and 
form  as  to  fit  the  hand,  the  warmth  of  which  causes  the  ethyl 
chloride  to  be  projected  against  the  desired  spot.  In  this  way  a 
small  area  of  skin  can  be  frozen  in  a  few  seconds.  The  proper 
degree  of  refrigeration  has  been  reached  when  the  skin  becomes 
frosty.  Freezing  beyond  this  stage  does  not  increase  the  anes- 
thesia and  may  lead  to  sloughing.  The  instruments  for  the  oper- 
ation should  be  previously  arranged  so  that  no  time  be  lost  be- 
cause the  duration  of  the  anesthesia  is  very  short. 

The  method  is  used  chiefly  for  the  opening  of  small  abscesses  or 
anesthetization  of  the  skin  preliminary  to  aspirations  or  injec- 
tion anesthesia.  Here  it  serves  a  very  useful  purpose,  since  it 
eliminates  the  initial  pain  of  infiltration  anesthesia;  and  con- 
versely, infiltration  anesthesia  may  be  used  to  prevent  the  pain 
caused  by  the  thawing  out  of  the  tissues  after  freezing.  By  the 
combination  of  these  two  methods  it  is  possible  to  carry  out  pain- 
lessly procedures  otherwise  very  painful.  If  primary  union  of 
an  incision  is  expected,  freezing  anesthesia  should  not  be  used  on 
account  of  its  interference  with  the  vitality  of  the  tissue. 


CHAPTER  II 


TECHNIC  OF  ADMINISTRATION 

Suitable  instruments  kept  in  good  condition  are  essential  to 
success  in  local  anesthesia.  Dull  knives  cause  pressure  on  dis- 
tant nerves  and  give  the  patient  discomfort  at  the  outset  when  he 
is  most  open  to  suggestions  of  doubt.  Dull  scissors  pinch,  but  do 
not  cut.  Badly  working  forceps  pull  unnecessarily  upon  the  tis- 
sues. A  dull  and  rusty  needle  and  a  leaking  syringe  will  defeat 
the  most  expert  operator. 

APPARATUS. — The  syringe  must  be  well  made  and  in  perfect 
condition,  and  adapted  to  its  purpose.  The  needle  must  be  sharp 
and  free  from  rust  and  long  enough  to  reach  the  desired  field. 
The  beginner  is  likely  to  underestimate  the  depth  of  the  sensi- 
tive tissue  and  use  a  needle  too  short  to  reach  the  sensitive  area. 


Fig.  2.     Glass  barrel  metal  mounted  syringe. 

The  most  desirable  syringe  is  one  with  a  metal  piston  and  glass 
barrel  with  metal  mountings.  All-glass  syringes  have  the  disad- 
vantage that  the  tip  upon  which  the  needle  fits  is  easily  broken 
off.  The  Record  syringe  is  the  best  on  the  market  and  can  be  ob- 
tained in  any  desired  size.  The  piston  is  of  metal  and  must  be 
boiled  separate  from  the  barrel. 

If  the  piston  does  not  work  smoothly  within  the  barrel,  fluid 
will  be  expelled  unequally  and  cause  pain  by  the  sudden  dilata- 
tion of  the  tissues.  The  most  common  fault  of  syringes  is  that 
the  barrel  differs  in  calibre  in  different  portions.  In  the  narrow 
portions  the  piston  works  with  difficulty,  while  in  the  wider  por- 
tions it  permits  the  fluid  to  leak  back.  Nearly  all  my  operations 
have  been  done  with  an  ordinary  2$  minim  syringe  (Fig.  2), 

25 


26 


Surgical  Operations  with  Local  Anesthesia 


which  is  the  most  desirable  size  for  endermic  infiltration, 
particularly  in  very  sensitive  tissue.  In  operations  which  require 
a  large  amount  of  fluid  a  syringe  of  greater  capacity  is  conven- 
ient. For  deep  nerve  blocking,  as  about  the  base  of  the  skull, 
a  syringe  of  5  cc.  capacity  is  convenient  (Fig.  3).  The  greater 


Fig,  3.     Five  cc.  Record  syringe 

the  diameter  of  the  barrel  the  greater  the  pressure  required  to 
force  the  fluid  out  of  the  needle.  The  difficulty  of  gentle  infil- 
tration increases  in  proportion  to  the  diameter  of  the  piston. 
For  this  reason  large  syringes  .can  be  used  only  for  the  edema  - 
tization  of  the  loose  areolar  and  muscular  tissues,  which  indeed 
require  no  anesthetic. 

Some  operations  require  a  special  syringe.     In  deep  cavities, 
as  in  operations  on  the  cervix,  an  extension  tube  is  desirable 


Fig.  4.     All-metal  syringe  with  extension  for  use  in  throat  and  pelvic 

operations.     The  extension  may  be  used  on  the  glass 

metal  mounted  syringe  (Fig.  2). 

(Fig.  4).  For  dental  work  a  more  powerful  instrument  (Fig. 
5)  is  needed  because  of  the  density  of  the  tissue  to  be  injected. 
For  this  purpose  all-metal  syringes  are  preferable  because  the 
glass  barrel  will  not  stand  the  high  pressure  required. 


Surgical   Operations  with  Local  Anesthesia  27 

Not  less  important  than  the  syringe  is  the  needle.  A  variety 
of  sizes  and  lengths  should  be  at  hand  for  special  purposes.  For 
endermic  infiltration  a  needle  2  to  4  cm.  long  with  a  diameter  of 
0.5  mm.  is  best.  For  infiltrating  the  abdominal  wall  a  needle  of 
this  size  is  usually  long  enough,  but  in  fat  abdomens  one  4  or  6 
cm.  long  may  be  needed.  For  infiltrating  the  anal  sphincter  and 
the  levator  ani  muscles  a  needle  6  or  8  cm.  long  and  0.7  mm. 
thick  is  desirable.  For  deep  cranial  injections  needles  12  cm. 
long  and  0.9  mm.  thick  are  required. 

The  character  of  the  point  of  the  needle  is  of  importance.  For 
endermic  infiltration  it  is  important  to  have  a  needle  with  a  sharp 
point  because  it  is  easier  to  penetrate  the  dense  cutaneous  tissue. 


Fig.  5.     All-metal  dental  syringe. 

For  deep  injections  about  vessels  a  sharp  pointed  needle  increases 
the  danger  of  penetrating  a  vessel.  For  such  injections,  there- 
fore, a  needle  with  a  point  representing  a  more  obtuse  angle  is 
demanded. 

Special  needles  have  been  devised  for  special  purposes.  Curved 
needles  for  injecting  about  the  base  of  tumors  are  superfluous. 
They  are  expensive,  not  easy  to  obtain  and  are  easily  broken. 
The  angled  needles  for  use  in  dental  operations  are  very  conve- 
nient. Appliances  for  marking  the  depth  to  which  the  needle  is 
passed  or  needles  marked  with  a  scale  are  unnecessary.  A  bit 
of  cork  through  which  the  needle  can  be  passed  serves  quite  as 
well. 

With  careful  cleansing  needles  can  be  used  repeatedly  and 
when  slightly  damaged  may  be  restored  by  polishing  on  emery 


28  Surgical   Operations  with  Local  Anesthesia 

cloth  and  sharpening  on  a  small  stone.     For  operating  on  his 
friends  the  operator  will  do  well  invariably  to  use  a  new  needle. 

GENERAL  PREPARATION  OF  THE  PATIENT. — In  carrying  out  oper- 
ations under  local  anesthesia  the  most  important  factor  is  con- 
fidence on  the  part  of  the  operator  that  the  results  will  be  satis- 
factory. If  the  operator  is  apprehensive  the  patient  is  sure  to 
imbibe  his  lack  of  confidence.  Nothing  will  more  certainly  make 
for  failure  than  to  have  a  general  anesthetic  in  readiness  and  to 
assure  the  patient  that  he  will  be  given  ether  if  the  local  anesthe- 
tic fails.  Stopping  the  patients  ears  with  cotton  or  covering  his 
eyes,  unless  required  by  the  nature  of  the  operation,  serves  only 
to  disturb  him.  Besides,  the  expression  of  the  patient's  face  is 
the  operator's  gauge  of  success  in  his  anesthesia. 

It  is  desirable  that  any  patient  about  to  undergo  an  operation 
should  have  his  mental  and  physical  equipoise  disturbed  as  little 
as  possible.  This  is  doubly  important  if  the  operation  is  to  be 
under  local  anesthesia.  Unless  some  special  indication  exists 
no  great  departure  from  normal  living  is  required.  A  full  bath, 
a  restful  night's  sleep,  and  a  normal  bowel  movement  are  helpful 
alike  to  both  surgeon  and  patient.  A  patient  who  is  confined  to 
bed  for  a  period  of  days  should  make  his  dietary  harmonize  with 
the  enforced  inactivity.  I  usually  permit  the  patient  a  light 
breakfast  just  before  the  operation.  Purgation  and  starvation 
are  particularly  to  be  avoided  because  they  inspire  apprehension 
and  do  no  real  good.  If  the  patient  is  accustomed  to  enjoy  an 
after  breakfast  cigar  it  should  not  be  denied  him. 

SPECIAL  PREPARATION. — After  the  full  bath,  if  the  operation  is 
a  major  one,  the  region  is  washed  and  shaved.  Immediately  be- 
fore the  operation  the  field  is  painted  with  Tr.  Iodine,  either  full 
strength,  or  diluted  with  an  equal  quantity  of  alcohol.  In  opera- 
tions about  the  scrotum  or  anus  this  cannot  be  employed,  and  soap 
and  water  must  be  depended  upon.  The  use  of  iodine  has 
proven  reliable,  and  where  the  nature  of  the  skin  permits  its  use 
is  more  pleasant  to  the  patient  than  the  vigorous  scrubbing  with 
soap  and  water.  The  use  of  soap  is  undesirable  because  it  makes 


Surgical   Operations  with  Local  Anesthesia  29 

the  skin  slippery  and  renders  the  necessary  manipulation  in  skin 
infiltration  more  difficult.  Simple  cleansing  with  clear  water 
lessens  this  inconvenience  but  does  not  entirely  remove  it.  Where 
alcohol  can  be  employed  it  will  remove  the  soap  entirely.  About 
the  labia  and  scrotum  neither  iodine  nor  alcohol  can  be  employed 
because  of  the  irritation  produced ;  simple  rinsing  must  be  de- 
pended upon. 

The  preparation  of  the  instruments  and  accessories  is  of  course 
the  same  as  when  general  anesthesia  is  employed.  The  syringe 
should  be  sterilized  with  the  instruments.  The  receptacle  in 
which  the  solution  is  made  should  also  be  boiled.  Ordinary  one 
ounce  medicine  glasses  are  of  a  convenient  size  and  are  sufficient- 
ly accurate  for  the  purpose. 

THE  PRELIMINARY  HYPNOTIC. — If  the  patient  is  restless  and 
expresses  fear  of  his  ability  to  withstand  the  operation,  or  if  the 
operation  is  to  be  one  of  magnitude,  a  preliminary  dose  of  mor- 
phine may  be  given.  This  I  have  called  "removing  the  hyper- 
tension from  the  apprehension."  The  initial  dose  of  morphine 
likewise  lessens  the  pain  produced  by  tugging  on  parts  not  anes- 
thetized, especially  in  abdominal  operations.  The  morphine 
should  be  given  thirty  to  sixty  minutes  before  the  time  of  opera- 
tion. 

If  the  morphine  cannot  be  given  at  least  half  an  hour  before 
the  operation  is  to  begin  it  should  be  omitted  entirely,  for  in  the 
first  few  minutes  after  its  administration  it  often  excites  rather 
than  quiets.  The  dose  need  not  be  large;  1-6  to  1-4  grain  is  suf- 
ficient. Many  operators  use  larger  doses  than  these  or  repeat 
them  several  times.  This  no  doubt  makes  the  operation  easier, 
or  at  least  makes  a  careful  technic  less  imperative.  Operating  on 
a  patient  stupified  with  a  hypnotic  is  not  operating  under  local 
anesthesia  however.  The  large  dose  of  an  opiate  may  be  a  great- 
er menace  to  safety  than  a  general  anesthetic,  this  is  particularly 
true  in  diseases  of  the  kidneys. 

Pantopon  recommended  by  a  number  of  German  operators  in 
twice  the  dose  of  morphine  is  effective,  but  is  more  stupefying 


30  Surgical   Operations  with  Local  Anesthesia 

and  the  effect  lasts  longer  and  is  therefore  more  objectionable. 
The  addition  of  atropine,  hyoscine  or  scopolamine  to  morphine 
enhances  the  action  of  morphine  and  may  therefore  be  advan- 
tageous or  harmful  as  the  case  may  be.  In  operations  about  the 
mouth  and  trachea  these  drugs  are  useful,  while  in  operations 
about  the  ano-genital  region  they  are  objectionable,  because  they 
increase  the  tendency  to  urinary  retention. 

When  injection  of  the  anesthetic  solution  is  to  begin  the  patient 
should  be  placed  on  the  table  in  a  comfortable  position.  A  strain- 
ed attitude  may  be  more  trying  than  the  operation,  as  for  instance 
holding  the  legs  in  the  lithotomy  position  in  rectal  work.  Pillows 
under  the  head  and  in  the  small  of  the  back  may  aid  in  making 
the  patient  comfortable  and  assist  in  gaining  his  co-operation. 
He  may  be  allowed  to  see  the  preparation  of  the  instruments  in 
order  that  he  may  become  familiar  with  the  sound  of  their  ma- 
nipulation. He  may  be  engaged  in  conversation  about  some  mat- 
ter of  common  interest,  or  the  operator  may  relate  to  his  assist- 
ant the  success  of  some  similar  operation.  The  advantage  of 
faith  in  the  success  of  the  operation  is  incalculable,  and  the 
operator  should  spare  no  pains  in  acquiring  the  confidence  of  the 
patient.  The  operator  should  sit  down,  if  possible,  both  to  pre- 
vent fatigue  and  to  permit  more  delicate  and  accurate  manipu- 
lations. 

Before  the  initial  injection  is  made  the  patient  should  be  told 
that  the  first  prick  of  the  needle  will  cause  about  as  much  pain 
as  the  giving  of  an  ordinary  hypodermic  injection.  One  of  my 
patients  estimated  the  pain  as  about  "two  mosquito  power."  I 
have  used  this  expression  with  advantage  to  the  mental  poise 
and  comfort  of  other  patients.  This  forewarning  prepares  him 
for  the  slight  pain.  It  is  remarkable  how  far  such  minute  de- 
tail goes  toward  gaining  the  confidence  of  the  patient  and  estab- 
lishing his  faith  in  the  success  of  the  procedure.  If  the  initial 
prick  causes  the  patient  to  bellow  with  pain  the  operator  has  an 
indication  of  the  state  of  his  mind  and  renewed  efforts  must  be 
made  to  gain  his  co-operation. 


Stirgical   Operations  zvitli  Local  Anesthesia  31 

METHODS  OF  INJECTION. — Before  beginning  the  injection  the 
operator  must  plan  his  operation  in  detail.  The  neural  anatomy 
must  be  recalled  in  his  mind's  eye,  and  it  must  be  decided  by 
what  steps  the  various  sensitive  tissues  may  be  anesthetized. 


Fig.  6.     The  proper  method  ot  picking  up  a  fold  of  skin  in  beginning  infiltration. 
Pressure^whh  the  thumb  and  fingeHs  made  until  the  skin  is  anemic.] 

The  order  in  which  the  various  steps  are  carried  out  depends 
on  the  anesthetic  used,  the  nature  of  the  operation  and  the 
character  of  the  patient. 

A  number  of  methods  are  employed,  depending  on  the  size  and 
accessibility  of  the  nerves  involved  in  the  operation.  In  term- 
inal nerve-endings  the  anesthetic  fluid  can  most  advantageously 


32 


Surgical  Operations  with  Local  Anesthesia 


be  deposited  in  the  tissue  in  which  the  nerve  endings  lie,  namely, 
the  papillary  layer  of  the  skin.  This  method  is  called  endermic 
infiltration.  In  larger  nerves  the  solution  may  be  injected  di- 
rectly into  the  nerve  sheaths.  This  is  called  nerve  blocking.  In 
large  nerves  this  can  be  done  without  exposing  the  nerves  as  in 
case  of  the  sciatic,  brachial  plexus,  etc.  In  smaller  ones,  as  in 
ilio-inguinal,  radial,  ulnar,  etc.,  it  is  necessary  to  first  expose  the 
nerve.  In  most  instances  the  infiltration  is  made  in  the  region 
of  the  nerve  and  dependence  is  placed  on  diffusion  of  the  fluid 
to  reach  the  nerve  fibres.  This  method  is  depended  upon,  for 


Fig.  7.     Showing  a  wheal  produced  by  endermic  injection.     The  rings  indicate  the  location  of 
subsequent  wheals  as  the  needle  is  pushed  forwards. 

instance,  in  hernia,  thyroid  operations,  etc.  When  the  operator 
has  no  definite  notion  as  to  the  location  of  the  nerve  supply  the 
tissues  are  infiltrated  diffusely.  This  may  be  called  edematisa- 
tion. 

These  several  methods  may  be  described  in  detail. 

ENDERMIC  INJECTION. — This  method  seeks  to  anesthetize  the 
end  organs  in  the  skin.  Anesthesia  is  dependent  in  part  on  pres- 
sure within  the  tissues,  but  the  chief  action  is  a  direct  chemical 


Surgical   Operations  with  Local  Anesthesia 


33 


one  upon  the  nerve  endings.  The  fluid  should,  therefore,  be 
brought  as  nearly  as  possible  in  direct  contact  with  the  nerve 
endings,  that  is,  in  the  papillary  layer  of  the  derma. 

In  beginning  the  injection,  one  picks  up  the  skin  between  the 
thumb  and  forefinger  of  the  left  hand  and  makes  a  firm  pressure 
(Fig.  6).  This  produces  a  local  anemia  rendering  the  skin  less 
sensitive  to  the  initial  prick  of  the  needle.  As  soon  as  the  point 
of  the  needle  has  entered  the  epidermis,  slight  pressure  on  the 


Fig.  8.     Endermic  infiltration.     The  needle  penetrates  the  papillary  layer  of 
the  skin  and  follows  along  this  plane. 

piston  forces  out  the  solution  which,  displacing  the  blood  in  the 
capillaries,  causes  a  blanching  of  the  skin  (Fig.  7).  In  this 
way,  the  fluid  as  it  escapes  from  the  needle  comes  in  contact  with 
the  nerve  endings  in  the  papillary  layer  of  the  skin  (Fig.  8). 
Anesthesia  rapidly  follows  the  blanching.  If  the  fluid  is  intro- 
duced rapidly  the  stretching  of  the  tissues  causes  pain  before  the 
anesthetic  effect  has  had  time  to  manifest  itself.  If  the  needle 
penetrates  too  deeply  the  fluid  escapes  into  the  loose  subcutan- 
eous tissue  and  edema  is  produced,  but  the  skin  is  unchanged  in 
color.  In  this  case  several  minutes  will  elapse  before  the  skin 


34  Surgical  Operations  zvith  Local  Anesthesia 

loses  its  sensibility.  Less  skill  is  required  to  introduce  the  fluid 
subdermically,  but  the  results  are  less  satisfactory. 

Blanching  from  the  first  endermic  injection  having  appeared 
the  needle  should  now  be  pushed  forward  nearly  to  the  opposite 
border  of  the  blanched  area  and  the  piston  again  pressed.  A 
blanched  area  is  produced  extending  for  a  distance  in  advance  of 
the  needle  (Fig.  7).  When  tne  needle  will  reach  no  farther  it 
is  withdrawn  and  introduced  again  near  the  edge  of  the  blanched 
area  and  the  injection  proceeds  as  before  until  the  entire  line  of 
the  proposed  incision  has  been  injected. 

As  soon  as  the  skin  line  is  finished  the  deep  injections  are 
made  by  passing  a  needle  through  it.  If  the  skin  only  is  to  be 
incised  it  may  be  done  very  soon  after  the  endermic  infiltration 
is  finished.  If  deep  injections  are  required  they  can  be  made  best 
before  incising  the  skin.  Care  should  be  taken  to  note  the  line 
of  infiltration,  for  if  properly  done  the  blanching  has  disappeared 
before  the  infiltration  has  all  been  made.  It  has  been  proposed 
that  the  line  of  injection  be  marked  by  drawing  silver  nitrate  or 
tincture  of  iodine  along  it,  provided  the  latter  drug  has  not  been 
used  to  sterilize  the  field  of  operation.  Although  the  blanching 
may  have  disappeared  the  general  direction  of  the  infiltrated 
line  can  be  retained  in  the  mind's  eye,  and  this  aided  by  the  pal- 
pable edema  of  the  skin  will  enable  the  operator  to  follow  ac- 
curately the  infiltrated  line. 

All  skin  and  mucous  surfaces  may  be  anesthetized  by  the  en- 
dermic method.  The  advantages  of  this  method  are  that  it  re- 
quires a  minimum  amount  of  fluid  and  that  anesthesia  appears 
as  soon  as  the  infiltration  is  complete.  The  surgeon's  skill  in  the 
use  of  local  anesthesia  is  better  shown  in  this  initial  step  than  in 
any  other.  The  needle  passes  just  within  the  skin  and  a  drop  of 
fluid  is  expressed.  Too  much  fluid  produces  a  burning  pain  due 
to  the  distention  of  the  tissue.  This  pain  is  of  momentary  dura- 
tion to  be  sure,  but  it  is  often  sufficient  to  shake  the  patient's 
faith  in  the  efficiency  of  the  method.  Each  time  the  needle  is 
advanced  to  the  edge  of  the  infiltrated  area,  the  same  gentle  pres- 


Surgical  Operations  wtV/i  Local  Anesthesia 


35 


sure  upon  the  piston  must  be  exerted.  If  the  injection  is  properly 
done  the  initial  prick  alone  causes  pain.  The  width  of  the  line 
to  be  infiltrated  may  be  varied  by  the  amount  of  fluid  injected ; 
the  more  fluid  is  forced  out  at  each  point  the  wider  the  area  in- 
filtrated by  the  fluid. 

After  the  injection  is  completed,  and  before  the  incision  is 
made,  a  test  of  the  sensitiveness  of  the  area  may  be  made  by 
pricking  the  skin  with  the  needle  of  the  syringe  or  the  point  of 
the  knife.  The  experienced  operator  omits  this  precaution  be- 
cause he  has  learned  by  experience  when  anesthesia  must  be 
complete.  An  error  commonly  made  is  to  extend  the  incision  be- 
yond the  infiltrated  area.  When  the  unanesthetized  skin  is 
reached,  the  sudden  pain  startles  the  patient  and  surprises  the 
operator  and  may  mar  the  success  of  the  operation. 


Fig.  9.     Subdermic  infiltration.     The  fluid  is  injected  into  the  loose  tissue 
immediately  beneath  the  skin. 


SUBDERMIC  INFILTRATION. — When  the  skin  or  mucous  mem- 
brane is  very  thin  endermic  infiltration  may  not  be  possible. 
The  solution  must  then  be  injected  immediately  beneath  the 
surface  (Fig.  9).  This  applies  not  only  to  thin  skin,  as  in  cir- 
cumcisions, but  also  to  fascia,  periosteum  and  peritoneum.  This 
method  requires  more  fluid  and  a  greater  length  of  time  before 
anesthesia  is  complete  because  the  fluid  must  traverse  the  sheaths 
of  the  nerve  filaments.  It  is  a  hit  or  a  miss  method  and  should 
be  employed  only  when  more  exact  methods  cannot  be  employed. 


36  Surgical   Operations  with   Local  Anesthesia 

NERVE  BLOCKING. — Some  operative  fields  are  supplied  by  ter- 
minal nerve  trunks.  These  regions  may  be  effectually  anesthet- 
ized by  injecting  directly  into  the  nerve  sheath.  In  certain  large 
nerves  this  may  be  done  without  exposing  the  nerve,  but  in  most 
cases  it  is  necessary  to  isolate  the  nerve  trunk  and  to  fix  it  care- 
fully with  the  tissue  forceps  (Fig.  loa)  before  attempting  to 
thrust  the  needle  into  it*  The  forceps  here  illustrated  (Fig.  lob) 
enable  one  to  pick  up  the  nerve  with  the  greatest  gentleness. 
By  grasping  the  nerve  in  the  hollow  portion  of  the  forceps  (Fig. 
lob),  and  passing  the  needle  within  the  grasp,  the  forceps  form 


Fig.  10.     Method  of  picking  up  a  nerve  for  endoneural  injection,     a.    Method 
of  grasping  the  nerve,     b.    Hollow  tip  of  forceps  is  shown  natural  size. 

a  constriction  about  the  needle;  the  fluid  injected  distends  the 
rerve  sheath  like  a  sausage  and  may  be  made  to  traverse  some 
inches  of  the  sheath.  The  entire  area  supplied  by  the  nerve  may 
then  be  operated  upon  without  fear  of  producing  pain.  This  is 
the  ideal  method  of  anesthetization  when  the  trunk  of  the  nerve 
supplying  the  entire  region  to  be  operated  upon  is  accessible.  It 
is  the  method  employed  in  major  operations  upon  the  extremi- 
ties and,  combined  with  skin  infiltration,  it  constitutes  the  method 
introduced  by  dishing  for  inguinal  herniotomy.  Unfortunately 
this  method  is  applicable  only  when  the  nerve  trunks  large  enough 


Surgical   Operations  with   Local  Anesthesia  37 

to  be  directly  injected  are  exposed  during  the  course  of  the 
operation  or  are  easily  reached  by  a  preliminary  incision. 

In  most  cases  the  operator  must  depend  upon  the  accuracy  of 
his  anatomic  knowledge  to  inject  the  fluid  into  a  deeply  lying- 
nerve  trunk  or  at  least  into  its  immediate  vicinity.  This  is  illus- 
trated by  regions  such  as  the  foramen  ovale.  the  inferior  maxil- 
lary canal,  and  the  intercostal  and  abdominal  nerves.  If  the  nerve 
is  directly  injected  anesthesia  takes  place  instantly.  In  these 
deeply  lying  nerves  direct  injection  is  not  often  possible  unless 
their  locations  are  fixed  by  reason  of  their  exit  from  some  fora- 
men or  notch.  Ordinarily  the  best  the  surgeon  can  do  is  to 
place  the  solution  as  near  the  nerve  as  possible.  The  fluid  then 
reaches  the  nerves  by  diffusion. 

The  more  recent  marked  advances  in  local  technic  have  been 
in  the  direction  of  blocking  deep  nerves,  and  have  made  possible 
many  major  operations  which  heretofore  had  been  done  only 
under  general  anesthesia.  This  is  true  notably  of  operations 
upon  the  jaw.  For  these  deep  blockings  novocain  and  epinephrin 
is  the  anesthetic  of  choice  because  of  its  more  rapid  diffusibility. 
The  addition  of  chlorbutanol  apparently  hastens  the  diffusion 
because  this  substance  is  a  lipoid  solvent.  It  is  in  addition 
slightly  anesthetic.  When  the  nerve  is  exposed  quinine  can  be 
used  because  of  its  more  enduring  effect. 

EDEMATIZATION. — (Schleich's  method).  The  distension  of  the 
tissues  with  fluid  was  introduced  by  Schleich  in  order  to  secure 
anesthesia  from  solutions  of  cocain  too  weak  to  act  by  infiltra- 
tion. The  fluid  is  injected  into  the  loose  tissue  irrespective  to 
the  position  of  the  nerves.  The  weak  solutions  were  used  because 
stronger  ones  were  dangerous.  The  method  is,  therefore,  a 
makeshift  to  overcome  the  dangers  of  the  drug  employed.  It 
was  first  used  with  cocain  solutions  and  is  described  in  connection 
with  that  drug. 

The  method  is  properly  used  only  in  loose  tissue  which  con- 
tains but  few  nerves  ;  in  regions  particularly  sensitive  or  where 
larger  nerve  trunks  are  involved  it  is  inefficient.  With  increased 


38  Surgical  Operations  with  Local  Anesthesia 

experience  and  the  use  of  safer  drugs  the  method  has  gone  large- 
ly out  of  use,  but  it  is  still  useful  where  tissues  are  to  he  dissected, 
as  in  the  ligation  of  vessels,  in  the  search  for  nerve  trunks  for 
the  purpose  of  nerve  blocking,  and  particularly  to  facilitate  the 
separation  of  tumors  from  their  capsule,  as  in  thyroidectomy,  etc. 
Where  tissues  are  to  be  accurately  united  again,  as  in  the  opera- 
tion for  hernia,  the  method  is  objectionable  since  it  interferes 
with  the  coaptation  of  the  wound  edges,  though  most  of  the  fluid 
escapes  when  the  incision  is  made.  The  method  is  particularly 
useful  to  the  novice  and  may  be  used  for  many  purposes  in  the 
absence  of  a  finished  technic.  Quinine  is  seldom  used  by  this 
method.  An  undesirable  infiltration  of  the  tissue  follows. 

THE      SEQUENCE      OF      ENDERMIC      INFILTRATION      AND      NERVE 

BLOCKING. — Generally  two  or  more  of  these  methods  are  com- 
bined in  one  operation.  Nearly  always  endermic  infiltration  is 
employed  for  the  skin  and  nerve  blocking  in  some  of  its  forms 
or  edematization  is  added  to  anesthetize  the  deeper  tissues. 
Which  of  these  shall  be  done  first  is  a  matter  of  election. 

Two  general  plans  may  be  described.  The  method  employed 
almost  universally  in  my  own  work  and  the  one  described  in 
these  pages  seeks  to  anesthetize  the  skin  first.  After  the  line 
of  skin  infiltration  has  been  made  the  deeper  tissues  are  infiltra- 
ted by  passing  the  needle  in  the  line  previouslv  infiltrated.  This 
method  has  the  advantage  that  only  the  initial  prick  is  perceived 
bv  the  patient  while  all  other  punctures  are  made  in  anesthetized 
skin.  It  has  the  disadvantage  that  the  operator  must  determine 
the  direction  and  extent  of  the  operation  before  the  injection 
is  begun.  This  is  the  most  delicate  method,  and  I  believe,  is  the 
one  best  adapted  to  the  sensitive  nervous  American. 

The  other  method  is  the  one  generally  employed  by  German 
surgeons  and  those  Americans  who  have  followed  the  German 
lead.  This  method  seeks  to  reach  the  chief  nerve  trunks  as  the 
first  act  in  the  operation.  This  necessitates  the  plunging  of 
needles  of  sufficient  length  deeply  into  the  tissue.  Two  or  more 
of  these  punctures  are  necessary.  After  the  deep  infiltration 


Surgical   Operations  with  Local  Anesthesia  39 

is  made  the  skin  is  infiltrated.  This  method  has  the  advantage 
that  niceties  of  planning  and  of  technic  are  not  demanded  and 
that  the  solution  is  brought  at  once  in  contact  with  the  chief 
nerve  supply  of  the  part.  The  chief  disadvantage  lies  in  that 
several  unanesthetized  points  must  be  punctured  with  a  relatively 
heavy  needle  and  the  needle  must  be  passed  for  some  depth  into 
the  tissue.  Both  these  acts  are  more  or  less  disturbing  to  the 
patient  in  the  earlier  stages  of  the  operation  before  his  full  con- 
fidence is  gained. 

INTRAVENOUS  ANESTHESIA. — (Bier,  Berlin.,  klin.  Woch.,  1909, 
No.  n).  The  following  is  quoted  from  Hartel  (Wien,  wied. 
Woch.  1909,  No.  35)  :  "The  patient  is  prepared  in  the  usual 
manner  for  operation.  The  affected  extremity  is  completely 
disinfected  and  protected  with  sterile  dressings.  The  following 
instruments  are  held  in  readiness  for  the  anesthetization:  a 
glass  receptacle,  filled  with  carbolic  acid  solution,  containing  at 
least  three  bandages,  from  3^  to  6  meters  in  length,  made  of 
thin  rubber  (the  kind  of  rubber  used  for  constriction-bandages), 
and  provided  with  strings  at  the  rolled-in  end.  A  graded  Janet 
syringe  holding  50  to  100  grams  is  boiled,  rinsed  in  physiological 
salt  solution,  and  completely  filled  with  a  fresh  YZ  per  cent,  sterile 
novocain  solution  (0.9  natr.  chl.  100.0  aq.),  at  about  body  tem- 
perature. To  the  syringe  is  attached  a  tube  of  rubber  or  a 
Nelaton  catheter  about  as  thick  as  a  lead  pencil.  With  this 
tube  is  connected  a  canula  1.5  to  2.0  mm.  thick  and  provided 
with  a  stopcock ;  the  connection  being  made  through  an  inserted 
segment  with  bayonet  closure.  The  end  of  the  canula  is  blunl. 
and  has  a  few  indented  grooves  for  the  fixation  of  the  vein. 
We  also  need  a  Pravaz  syringe  with  Y*  Per  cent,  novocain  so- 
lution, i  scalpel,  2  small  three-pronged  sharp  hooks,  3  De- 
schamp's  needles  with  silk,  I  pair  fine  pointed  scissors,  2  small 
hook  forceps,  a  few  clamps,  ligature  threads,  needle  holders, 
and  a  few  silk  sutures. 

The  first  and  indispensable  preliminary  requirement  for  the 
success  of  the  anesthesia  is  complete  ischemia.     No  satisfaction 


4O  Surgical   Operations  with  Local  Anesthesia 

with  venous  anesthesia  is  possible,  unless  this  is  carefully  attend- 
ed to.  The  limb  is  raised  by  the  assistant,  the  operator  wraps 
it  from  the  fingers  or  toes  with  rubber  bandage  No.  I,  pressing 
the  blood  out  carefully  and  thoroughly  until  a  short  distance 
above  the  site  of  the  injection;  the  expulsion  bandage  is  then 
temporarily  fixed  in  place.  Immediately  above  it,  the  permanent 
Esmarch  bandage  is  applied  as  tightly  as  possible  in  turns,  only 
partly  covering  each  other,  so  that  the  result  is  not  a  constricting 
strand,  but  as  wide  a  constricting  surface  as  possible.  Expul- 
sion bandage  No.  i  is  then  removed,  as  far  as  the  point  above 
which  the  lower  ischemia  bandage  No.  3  is  to  be  applied.  As 
bandage  No.  i  is  being  removed,  the  limb  should  appear  clear 
white  in  color;  if  it  is  still  red  or  bluish,  the  prospects  are  poor 
for  a  satisfactory  anesthesia.  While  the  expulsion  bandage  is 
still  in  place  at  the  peripheral  end,  the  lower  Esmarch  bandage 
No.  3  is  applied  in  a  similar  fashion  as  bandage  No.  2,  and  the 
expulsion  bandage  is  entirely  removed.  The  entire  procedure 
is  more  easily  accomplished,  in  fact,  than  described  in  words. 

There  are  now  two  constricting  bandages  around  the  ischemic 
extremity.  The  principle  of  venous  anesthesia  consists  in  filling 
the  segment  between  the  two  bandages  with  a  novocain  solu- 
tion, by  way  of  a  skin  vein,  and  in  this  manner  to  bring  all  the 
nerve  terminals  situated  between  the  bandages  in  contact  with  the 
novocain  solution,  by  the  natural  route  of  the  vascular  supply, 
constituting  direct  anesthesia.  In  the  second  place,  all  the  nerve 
trunks  passing  though  this  region  toward  deeper  parts  of  the 
limb  are  in  the  same  way  made  incapable  of  conduction-indirect 
anesthesia.  The  space  between  the  two  bandages  should  not  be 
narrower  than  about  10  cm.  and  not  wider  than  about  25  cm.  (i 
to  3  hand's  width).  In  the  case  of  peripheral  segments  of  limbs, 
direct  anesthesia  may  be  carried  out  under  application  of  a  single 
bandage,  but  this  should  never  be  placed  higher  than  the  middle 
of  the  forearm,  or  lower  leg. 

It  is  dangerous  to  select  other  veins  for  the  injection  than  the 
well-known  large  subcutaneous  veins,  which  should  be  looked 


Suryica!   Operations  with   Local  Anesthesia  41 

for  according  to  their  topographical  relations.  Often  enough,  a 
large  blue  vein  will  shimmer  most  temptingly  through  the  skin 
at  some  other  point,  turning  out  to  be  nothing  but  a  narrow  mem- 
brane, when  exposed  under  ischemia,  which  does  not  permit  the 
introduction  of  the  canula.  Hence,  the  course  of  the  skin  veins 
should  first  be  studied.  The  position  of  these  vessels  is  usually 
described  rather  superficially,  and  often  inaccurately,  in  the  text- 
books of  anatomy.  As  a  rule,  the  vein  can  be  felt  as  a  rolling 
strand  under  the  skin  by  very  gentle  palpation ;  in  fat  and  youth- 
ful individuals,  the  examiner  must  depend  on  his  topographical 
knowledge.  The  large  saphenous  vein  lies  at  the  inner  aspect  of 
the  thigh,  far  backward  on  the  abductors,  behind  the  sartorius 
muscle ;  at  the  knee  joint,  it  should  be  sought  for  about  a  thumb's 
width  behind  the  posterior  margin  of  the  femoral  condyle ;  in 
the  leg,  the  vein  will  be  found  lying  upon  the  calf  muscles  at  the 
mesial  margin  of  the  subcutaneous  tibial  surface ;  farther  down- 
ward, it  lies  in  front  of  the  internal  malleolus.  The  small  saph- 
enous vein  enters  more  rarely  into  consideration.  The  basilic 
vein  of  the  upper  arm  lies  in  the  internal  bicipital  groove  and  is 
frequently  concealed  under  the  fascia  after  a  short  course.  It 
is  usually  more  serviceable  than  the  cephalic  vein  which  lies  on 
the  anterior  external  side  of  the  upper  arm,  almost  in  the  midst 
of  the  muscular  ridge  of  the  biceps. 

The  veins  at  the  bend  of  the  elbowT  and  of  the  forearm  take 
a  variable  course,  and  are  usually  visible  under  the  skin.  Only 
the  middle  ulnar  vein,  or  the  basilic  vein  of  the  forearm  should 
be  selected,  avoiding  all  side  branches.  It  should  further  be  kept 
in  mind  that  the  basilic  vein  is  accompanied  by  the  middle  cuta- 
neous nerve  of  the  forearm,  and  the  large  saphenous  vein  in  the 
leg  is  accompanied  by  the  saphenous  nerve ;  these  structures 
should  be  carefully  preserved.  In  order  to  be  sure  to  find  the 
vein,  it  is  advisable  to  study  its  course  prior  to  the  expulsion  of 
the  blood  from  the  limb,  marking  the  site  for  the  injection  of  the 
needle  by  a  needle  prick,  or  similar  device,  or  possibly  by  expos- 
ing the  vein  while  it  is  still  filled  with  blood. 


42  Surgical  Operations  with  Local  Anesthesia 

Immediately  below  the  upper  Esmarch  bandage,  the  trans- 
verse skin  incision  which  is  to  serve  for  the  exposure  of  the  vein 
is  rendered  anesthetic  for  a  distance  of  2  to  3  cm.  by  the  intra  and 
subcutaneous  injection  of  3/2  per  cent,  novocain  solution;  the  skin 
is  then  divided  and  is  pulled  forcibly  apart  with  two  sharp  hooks 
by  the  assistant.  As  a  rule,  this  causes  the  vein  to  appear,  but  in 
case  it  fails  to  present  itself,  it  is  necessary  to  go  deeper  into  the 
layer  of  fat  down  to  the  fascia.  This  illustrates  the  superiority 
of  the  transverse  incision  which  guards  against  missing  the  vein 
by  passing  on  its  side  into  the  depth  of  the  tissues.  As  soon  as 
the  vessel  appears  it  is  grasped  with  Deschamp's  No.  I  and  tied 
as  high  as  possible  at  the  central  end.  The  sharp  hooks  are  re- 
moved and  the  vein  is  lifted  up  by  the  ligature  thread.  The  ves- 
sel is  held  with  Deschamp's  No.  2  under  the  peripheral  end ;  the 
thread  is  left  untied,  and  serves  to  raise  the  vein  at  the  other 
end.  The  full  syringe  with  the  canula,  stopcock  closed,  is  lying 
near  the  limb  ready  for  introduction.  An  oblique  lateral  incision 
is  made  with  the  pointed  scissors,  in  the  vein  which  is  stretched 
out  and  flattened,  until  the  lumen  gapes ;  the  lower  corner  of  the 
gap  is  held  with  the  small  forceps  and  the  canula  is  introduced 
deeply  into  the  lumen,  in  a  peripheral  direction.  The  assistant 
ties  the  second  thread,  while  the  operator  slowly  withdraws  the 
canula  until  the  thread  slips  into  the  groove :  the  canula  is  thus 
held  in  place.  The  assistant  holds  the  canula  exactly  in  the 
direction  of  the  vein,  which  is  put  on  the  stretch  by  the  central 
thread;  the  operator  opens  the  stopcock  and  slowly  injects  the 
fluid,  sometimes  under  considerable  pressure.  In  case  some 
of  the  solution  oozes  out  from  small  vessels  in  the  wound  which 
have  been  divided,  these  should  at  once  be  caught  by  clamps.  If 
the  injection  is  successful,  the  superficial  veins  of  the  segment  will 
now  be  seen  swelling  up  and  becoming  very  prominent  for  a 
short  time,  after  which  the  entire  segment  becomes  still  whiter 
in  color  than  heretofore.  Sometimes  a  valve  is  found  to  close 
and  oppose  a  strong  resistance  against  the  flow,  but  this  is  soon 
overcome  by  continuous  pressure,  and  the  valve  yields.  The 


Surgical   Operations  with  Local  Anesthesia  43 

quantity  of  the  solution  to  be  injected  amounts  to  about  80  cc. 
for  the  leg,  and  about  50  cc.  for  the  arm.  A  few  c.  cm.  more 
than  necessary  should  always  be  injected,  in  view  of  the  loss 
incurred  by  escape  of  fluid  from  the  wound.  The  stopcock  is 
now  closed,  and  the  tube  is  removed  from  the  canula,  by  means 
of  the  bayonet  closure.  The  withdrawal  of  the  canula,  which  is 
either  done  at  this  time,  or  postponed  until  the  end  of  the  opera- 
tion, in  view  of  possible  further  injections,  is  accomplished  in 
such  a  way  that  a  Deschamp's  No.  3  is  placed  under  the  vein, 
peripherally  from  the  canula,  the  vessel  is  tied,  thread  2  is  divi- 
ded, and  the  canula  is  withdrawn.  The  wound  is  closed  by 
sutures. 


CHAPTER  III 

LOCAL  ANESTHESIA  IN  THE  PREVENTION  OF  AFTER-PAIN 
AND  SHOCK 

AFTER-PAIN. — After-pain  is  prevented  by  local  anesthesia  jusi 
as  long  as  the  anesthesia  lasts.  After  the  effect  of  the  anesthesia 
has  passed  oft"  the  patient  is  conscious  of  the  same  sensations  in 
the  region  of  the  wound  as  though  no  anesthesia  had  been  used. 
The  duration  of  control  is  therefore  a  question  of  the  action  of 
the  drug  employed. 

The  degree  of  after-pain  is  dependent  upon  the  region  operated 
upon  and  upon  the  manner  in  which  the  operation  is  done.  The 
amount  of  complaint  one  hears  from  any  given  patient  depends 
upon  his  sensitiveness  to  pain  and  upon  his  ability  to  give  vocal 
expression  to  his  sensations.  The  failure  of  correlation  of  these 
two  factors  makes  judgment  difficult  in  a  given  case  or  in  a  series 
of  cases. 

After-pain  is  dependent  largely  upon  constriction  of  the  nerve- 
bearing  tissue  by  ligatures  or  sutures  and  only  in  a  small  measure 
by  the  actual  division  of  tissues.  The  incision  of  the  skin  pro- 
duces a  burning  pain  which  lasts  a  number  of  hours  only,  and  is 
not  intense,  described  usually  as  a  burning,  but  ligation  of  painful 
masses  is  intense  and  lasts  until  the  ligature  begins  to  absorb  or 
cut  through  the  tissue  or  the  constricted  tissue  begins  to  undergo 
an  anemia  necrosis.  Those  who  have  not  had  the  opportunity 
of  studying  the  effect  of  gentle  and  firm  ligation  upon  themselves 
will  hardly  fully  appreciate  the  truth  of  these  statements. 

If  one  fully  appreciates  the  importance  of  care  in  technic  as 
a  factor  in  the  avoidance  of  after-pain,  operations  under  local 
anesthesia  furnish  him  a  good  opportunity  to  study  the  relative 
sensitiveness  of  tissues.  In  his  early  efforts  at  producing  local 
anesthesia  his  imperfect  technic  affords  him  abundant  opportunity 
to  learn  which  tissues  are  sensitive  and  which  are  not.  This 

44 


Surgical   Operations  with  Local  Anesthesia  45 

information  will  be  valuable  after  he  has  so  perfected  his  technic 
that  he  no  longer  produces  pain,  for  he  then  knows  which  tissues 
must  be  avoided  in  making  ligations.  Even  then  operations  under 
the  most  perfect  local  anesthesia  make  it  possible  to  study  the 
effects  of  a  technic  on  the  production  of  after-pain  much  better 
than  do  operations  under  general  anesthesia.  The  reason  for  this 
is  that  the  patient  operated  upon  under  local  anesthesia  retains 
his  general  sensibilities  and  consciousness,  and  is  able  to  give  a 
good  account  of  the  beginning  and  degree  of  the  after-pain,  an 
estimate  which  the  disturbed  brain  of  the  recently  etherized 
patient  is  incapable  of  doing.  Given  a  large  number  of  indivi- 
duals operated  upon  in  the  same  way  one  gets  a  measure  of 
comparison  to  a  like  number  operated  upon  in  a  different  man- 
ner for  the  same  affection.  The  larger  the  number  of  patients 
operated  the  less  the  individual  idiosyncrasies  impress  them- 
selves. For  instance,  if  a  hundred  patients  are  operated  upon 
for  hernia  without  giving  attention  to  extreme  delicacy  in  liga- 
tion  and  suture,  and  a  like  number  of  patients  in  which  every 
attention  is  given  to  gentle  technic,  one  gets  a  general  impression 
of  the  importance  of  care  in  technic. 

It  is  more  difficult  to  determine  the  difference  in  after-pain 
when  operating  under  ether  because  the  reaction  of  the  patient 
is  so  different.  The  patient  as  he  awakens  from  the  anesthetic 
has  a  disturbed  sensibility,  and  his  expressions  of  pain  are  more 
apt  to  be  dependent  upon  his  loquacity  than  upon  his  sensitive- 
ness to  pain.  Again,  he  may  be  nauseated  to  such  a  degree  that 
his  time  is  so  occupied  with  the  emesis  basin  that  the  after-pair, 
suffered  is  relegated  to  a  secondary  place  in  his  memory. 

It  is,  therefore,  the  student  operating  under  local  anesthesia 
who  has  the  best  opportunity  to  study  after-pain  in  its  purely 
physical  relations.  Far  too  little  attention  has  been  given  to 
this  problem.  The  enthusiast  in  his  delight  with  having  per- 
formed operations  without  pain  is  too  apt  to  ignore  or  minimize 
what  the  patient  has  to  endure  after  he  returns  to  his  bed.  Yet 
this  phase  is  quite  as  important  as  the  performance  of  a  pain- 
less operation. 


46  Surgical   Operations  with  Local  Anesthesia 

The  problem  has  become  somewhat  confused  by  surgeons 
because  of  the  fact  that  most  operators  give  a  preliminary  dose 
of  morphine  before  beginning  the  operation  under  local  anes- 
thesia. The  after-pain  will  then  be  modified  by  the  morphine 
to  a  degree  dependent  upon  the  amount  of  the  drug  given  and 
the  patient's  sensitiveness  to  it.  For  this  reason  patients  operated 
upon  under  a  general  anesthetic  will  suffer  more  unless  they 
too  receive  a  like  amount  of  morphine.  When  this  point  is  kept 
in  mind  it  will  be  observed  that  the  degree  of  after-pain  suffered 
after  local  anesthesia  and  after  general  is  not  very  great.  At  any 
rate,  patients  who  have  undergone  like  operations,  for  instance, 
hernias  or  block  dissections  of  the  neck,  once  under  general 
anesthesia  and  once  under  local,  praise  the  latter  because  they 
escape  the  ether,  after-pain  being  seldom  mentioned. 

The  above  remarks  are  based  upon  observations  made  with 
cocain  and  novocain  and  drugs  of  that  class.  Quinine  and  urea 
hydrochloride  is  the  only  drug  available  for  local  anesthesia 
which  has  a  notable  influence  upon  the  control  of  after-pain. 
Properly  used  this  drug  is  capable  of  a  very  decided  ameliora- 
tion of  pain  after  operation.  By  the  use  of  this  drug  it  is  possible 
to  control  the  after-pain  for  some  days.  Unfortunately  it  re- 
quires a  considerable  experience  with  the  use  of  this  drug  before 
these  results  can  be  secured  with  any  degree  of  regularity.  An 
injudicious  use  of  the  drug  may  fail  to  secure  these  results  and 
after-pain  may  actually  be  increased  or  wound  healing  may  be. 
disturbed.  The  factors  upon  which  the  successful  use  of  this 
drug  depends  can  best  be  set  forth  in  the  specific  operations  in 
which  it  is  indicated.  This  detail  will  be  found  in  the  succeeding 
chapters. 

The  foregoing  remarks  have  to  do  with  the  summation  of  after- 
pain  following  an  operation  without  any  attempt  to  separate 
the  pain  produced  by  the  mechanical  acts  of  the  operation  and 
that  due  to  the  introduction  of  the  foreign  substance,  the  novo- 
cain-epinephrin  or  quinine  solution.  That  the  use  of  the  local 
anesthetic  is  itself  productive  of  after-pain  has  seldom  been  re- 


Surgical  Operations  with  Local  Anesthesia  47 

ferred  to  in  the  literature,  but  that  it  adds  something  to  the  sum 
total  of  after-pain  must  be  evident  to  experienced  experimental- 
ists. The  degree  of  after-pain  the  anesthetic  produces  is  depen- 
dent upon  the  anesthetic  used,  the  method  of  its  use,  the  amount 
used  and  particularly  upon  the  character  of  the  tissue  in  which 
it  is  used.  Unfortunately  there  are  great  individual  variations 
which  contribute  to  an  inconstancy  of  results  which  seems  to 
defy  analysis.  The  personality  of  the  individual,  the  degree  of 
local  reaction  and  the  technic  of  operation  enter  here  to  confuse 
the  final  analysis. 

The  after-pain  which  results  from  the  use  of  the  local  anes- 
thetic results  in  the  first  place  from  the  injury  produced  by  the 
needle  itself.  If  the  needle  is  large  and  the  tissues  are  sensi- 
tive this  will  be  considerable.  About  the  fingers  and  toes  par- 
ticularly a  sensitive  area  lasting  several  days  is  produced.  The 
chief  factor,  however,  is  the  anesthetic  solution  itself.  Cocain 
leaves  but  little  after-pain  when  used  without  epinephrin.  No- 
vocain  when  used  alone  is  followed  in  15  to  30  minutes  by  a 
very  distinct  unpleasant  tingling  which  amounts  to  actual  pain 
in  the  more  sensitive  regions.  In  many  instances  this  is  followed 
by  a  very  distinct  hyperesthesia  lasting  for  several  hours.  These 
sensations,  though  delayed  from  one  to  three  hours,  are  aug- 
mented by  the  addition  of  epinephrin.  This  increase  in  after- 
pain  is  due  to  the  secondary  dilatation  of  the  vessels  after  the 
constricting  action  of  the  epinephrin  has  disappeared.  This 
dilatation  is  accompanied  by  an  actual  exudation  of  serum  aug- 
mented sometimes  by  the  escape  of  erythrocytes.  The  changes 
are  therefore  parallel  with  a  low  degree  of  acute  inflammation. 
These  conditions  are  restored  to  normal  within  a  few  hours. 
They  are,  as  one  might  expect,  most  severe  where  the  tissues 
are  abundantly  supplied  by  nerves  and  are  dense.  These  con- 
ditions are  met  by  the  anatomic  structures  of  the  fingers.  The 
lateral  and  palmar  surfaces  exhibit  this  to  a  greater  degree 
than  the  dorsal  surface.  The  loose  tissues  about  the  front  of 
the  neck  and  inner  surface  of  the  thigh  exhibit  it  but  little. 


48  Surgical   Operations  ivith  Local  Anesthesia 

The  local  effect  of  quinine  and  urea  hydrochloride  presents 
a  different  variety  of  problems.  The  long  duration  of  the  anes- 
thesia produced  by  the  agent  makes  it  possible  for  the  reactive 
processes  produced  by  the  chemical  irritation  of  the  drug  to  run 
their  course  before  sensation  is  restored.  This  is  true  only  for 
the  region  in  which  there  is  a  fibrin  exudate  produced  by  the 
drug  and  does  not  hold  for  the  region  made  anesthetic  but  in 
which  no  infiltration  has  occurred. 

The  marginal  hyperesthesia  that  often  accompanies  local 
anesthesia  has  been  briefly  referred  to  elsewhere  but  may  be 
mentioned  again  at  this  place.  If  an  area  a  cm.  in  diameter  is 
anesthetized  there  will  be  a  border  beyond  the  area  actually  in- 
filtrated which  is  more  sensitive  than  the  surrounding  normal 
skin.  The  degree  reached  by  this  hyperesthesia  is  sometimes 
astonishingly  great.  It  is  most  readily  observed  on  ones  own 
person,  but  may  readily  be  recognized  upon  patients.  For 
instance,  a  patient  complaining  of  pain  following  a  hernia  opera- 
tion will  find  relief  if  an  irritating  bandage  is  removed  and  will 
note  a  return  of  his  pain  if  the  region  beyond  the  wound,  say  a 
cm.  on  either  side,  is  gently  irritated. 

When  novocain-epinephrin  is  used  the  area  previously  anes- 
thetic becomes  hyperesthetic  when  the  effect  of  the  drug  has 
worn  off.  I  am  led  to  conclude  from  my  studies  that  the  sen- 
sation produced  after  the  effect  of  the  anesthetic  has  worn  off 
is  due  to  the  reaction  already  referred  to,  namely,  the  vascular 
dilatation  and  serous  exudate,  and  to  some  toxic  after  effect 
on  the  nerves.  The  evidence  of  this  is  found  in  the  fact  that  the 
hyperesthesia  extends  beyond  the  area  acted  upon  by  the  drug 
and  in  this  area  the  sensation  is  one  of  simple  hyperesthesia, 
\vhile  that  in  the  area  acted  upon  by  the  drug  the  sensation  is  a 
combination  of  superficial  sensitiveness  and  deep  soreness.  The 
latter  is  accounted  for  by  the  reaction  of  the  tissues  to  the  epine- 
phrin  above  mentioned. 

With  quinine  the  area  upon  which  the  drug  acts  does  not  be- 
come hypersensitive  and  the  problem  of  after-pain  concerns  it- 
self with  the  hyperesthetic  border  zone  only. 


Surgical   Operations  with   Local  Anesthesia  49 

The  practical  problem  resolves  itself  into  a  question  of  sim- 
ply avoiding  irritation  of  the  region  anesthetized  when  the  novo- 
cain-epinephrin  is  used  and  sparing  the  zone  about  the  actual 
region  of  infiltration  after  the  use  of  quinine.  This  resolves  itself, 
in  practice,  in  avoiding  nerve-bearing  tissues  in  making  ligatures. 
This  requires  that  vessels  be  isolated  before  ligation  and  that 
coaptation  sutures  be  applied  as  loosely  as  is  compatable  with 
the  proper  closure  of  the  wound.  In  the  use  of  quinine  for  the 
control  of  after-pain  the  ligation  suture  must  be  applied  in  tis- 
sue actually  infiltrated  by  the  drug  and  not  to  tissues  near  that 
directly  acted  upon  by  the  drug.  Thus  in  the  ligation  of  hemor- 
rhoids the  quinine  must  be  introduced  into  the  tissue  at  the 
actual  site  of  ligation  and  not  some  distance  beyond  the  point 
of  operation.  In  the  anesthetization  of  the  peritoneum,  if  the 
after-pain  is  to  be  ameliorated,  the  infiltration  must  be  made  in 
the  actual  line  of  incision  and  suture.  If  the  infiltration  is 
made  lateral  to  this  line,  after-pain  will  be  increased. 

The  reader  may,  if  he  has  had  abundant  clinical  experience, 
believe  he  discovers  paradoxes  in  the  above  statements.  It  is 
possible  that  the  regional  anastomosis  of  nerves  plays  a  part. 
Waldeyer  explained  early  restoration  of  sensation  in  peripheral 
regions  when  a  nerve  is  severed  by  the  supposition  that  a  neigh- 
boring trunk  takes  up  in  part  the  innervation  of  the  injured 
companion  through  anastomosing  nerve  plexuses  not  ordinarily 
functioning.  In  the  same  way  it  is  possible  that  an  area  made 
anesthetic  by  blocking  with  quinine  recovers  sensation  through 
these  anastomoses  before  the  original  trunk  which  has  been 
blocked  recovers  its  function.  It  is  only  in  this  way  that  hyper - 
esthesia  can  be  explained  in  regions  at  one  time  anesthetic  be- 
fore the  nerve  has  recovered  from  its  block. 

To  the  pain  produced  by  the  local  action  of  the  anesthetic  we 
must  add  that  due  to  the  trauma  of  the  operation.  If  the  prob- 
lem were  one  of  simple  addition  we  might  represent  the  sum 
total  of  the  after-pain  present  by  x,  which  would  be  as  the  sum 
of  a,  the  pain  produced  by  the  anesthetic,  and  b,  the  pain  pro- 


5O  Surgical  Operations  ivith  Local  Anesthesia 

duced  by  the  operation.  We  would  then  have  the  following 
equation,  a  +  b  =  x.  Self-experimentation  and  careful  clinical 
observation  leads  to  the  conclusion  that  under  some  conditions 
the  after-pain  is  greater  than  the  simple  sum  of  a  and  b.  Then 
the  formula  would  read,  a  +  b  =  xn,  the  power  of  x  representing 
in  itself  an  unknown  quantity. 

This  latter  point  can  be  illustrated  by  comparing  operations 
done  by  trunk  blocking  and  those  done  by  local  infiltration.  A 
familiar  example  is  seen  in  amputations  of  the  fingers.  An  am- 
putation done  by  regional  infiltration  may  be  followed  by  more 
pain  than  one  done  under  general  anesthesia  or  by  nerve  trunk 
blocking,  and  is  greater  than  the  pain  produced  by  infiltrations 
made  in  these  regions  which  are  made  experimentally  for  the 
purpose  of  determining  the  amount  of  pain  produced  by  th*; 
operation  and  are  not  followed  by  an  operative  procedure.  In 
many  of  these  cases,  therefore,  it  would  seem  that  the  infiltra- 
tion, when  followed  by  operation,  results  in  pain  greater  than 
both  of  these  factors  combined.  This  may  be  explained  by  the 
fact  that  the  epinephrin,  when  its  effects  have  worn  off,  leaves 
the  vessel  walls  in  a  state  capable  of  responding  more  readily 
to  the  reactive  processes  in  the  healing  wound.  .This  excessive 
reaction  may  be  avoided  by  securing  the  anesthesia  by  infiltrat- 
ing the  nerve  at  some  distance  from  the  field  of  injury,  thus 
avoiding  the  local  effects  of  the  epinephrin  in  the  field  of  opera- 
tion. As  an  example  may  be  cited  the  familiar  operation  of 
the  amputation  of  a  digital  distal  phalanx.  If  the  nerves  be 
blocked  in  the  region  of  the  metacarpo-phalangeal  joint,  instead 
of  infiltrating  directly  the  region  to  be  operated  on,  the  after- 
pain  will  be  less.  As  a  fundamental  principle,  therefore,  it  is 
desirable  to  block  the  nerves  supplying  the  part  at  some  distance 
from  the  field  of  operation  rather  than  to  inject  the  actual  site 
of  therapeutic  attack.  The  foregoing  remarks  apply  with  double 
force  when  areas  already  the  site  of  inflammatory  reaction  are 
to  be  attacked. 

On  the  other  hand,  if  the  pain  following  operation  is  of  but 


Surgical  Operations  -with  Local  Anesthesia  51 

short  duration,  the  local  anesthetic  may  outlast  the  after-pain. 
The  smarting  pain  from  a  simple  skin  incision  lasts  only  a  few 
hours  and  the  novocain  lasting  two  hours  reduces  the  total  pain 
by  so  much. 

But  if  ligations  or  tight  suturing  is  necessary  the  after-pain 
lasts  much  longer  than  the  anesthetic  effect  of  the  novocain- 
epinephrin  and  the  local  anesthetic  may  actually  add  an  element 
to  the  sum  total  of  after-pain.  Before  attempting  to  control 
after-pain  by  means  of  local  anesthesia,  one  should  consider 
the  problems  in  all  possible  phases.  On  the  whole  by  avoiding 
those  factors  which  are  known  to  produce  after-pain  the  opera- 
tor will  accomplish  more  than  by  instituting  means  to  prevent  it. 

Fortunately  structures  that  are  sensitive  do  not  require  liga- 
tures or  firm  sutures  and  those  that  do  require  ligation  and  firm 
sutures  do  not  have  nerves.  For  instance,  in  the  closure  of  an 
abdominal  wound  the  peritoneum  should  be  very  gently  coapted 
with  fine  sutures.  The  fascia,  if  the  nerve-bearing  fat  be  pushed 
back,  is  without  nerves  and  may  be  firmly  sutured  without  the 
production  of  after-pain.  The  skin  is  the  structure  most  prolific 
of  after-pain  and  the  gentlest  means  possible  of  holding  it  in 
apposition  should  be  used. 

SHOCK. — Enthusiasts  are  apt  to  declare  that  in  painless  opera- 
tions under  local  anesthesia  there  is  no  shock.  If  the  profound 
depressed  states  observed  after  severe  injuries  or  prolonged 
unskillfully  performed  operations  under  a  general  anesthetic  are 
in  mind,  this  opinion  may  be  accepted.  Nevertheless  states  of 
exhaustion  do  follow  operations  properly  done  under  local  anes- 
thesia. There  is  no  rapid  pulse  or  perspiration,  to  be  sure,  but 
the  patient  lies  flat  in  bed  without  any  considerable  interest  in  his 
environment  and  is  apt  to  express  great  satisfaction  that  the 
operation  has  been  completed.  These  states  may  be  exemplified 
by  examples.  One  patient  operated  upon  for  a  large  umbilical 
hernia  climbed  off  the  table,  walked  to  her  room  and  climbed 
in  bed.  Some  hours  later  she  was  found  reading  the  morning 
paper,  which  occupation  she  interrupted  long  enough  to  berate 


52  Surgical  Operations  with  Local  Anesthesia 

herself  for  having  so  long  endured  her  affliction.  Another  wo- 
man of  the  same  age  and  physical  make-up  was  operated  on  for 
a  large  goiter.  She  climbed  off  the  table  unassisted  and  remarked 
to  her  husband  that  the  operation  was  altogether  painless.  As 
she  walked  out  of  the  room  she  inquired  if  it  would  be  necessary 
to  go  to  bed.  I  assured  her  she  could  go  anywhere  she  pleased. 
I  was  quite  sure  where  I  would  find  her  in  a  few  hours.  She  was 
in  bed  quite  flattened  out,  looked  exhausted  and  expressed  satis- 
faction that  the  operation  was  completed.  Neither  pulse  nor 
blood  pressure  were  affected.  She  did  not  sit  up  again  until  the 
afternoon  of  the  following  day. 

Still  a  more  pronounced  degree  of  depression  is  illustrated  in 
the  following:  a  block  dissection  of  the  neck  was  done,  remov- 
ing the  jugular  veins,  external  carotid  and  the  pneumogastric 
nerve  together  with  all  the  muscles  of  the  antero-lateral  quad- 
rant of  the  neck.  He  at  no  time  admitted  pain.  As  the  operation 
approached  the  base  of  the  skull  it  was  evident  that  his  general 
body  muscular  tonus  was  relaxing,  a  state  best  described  as  flat- 
tening out.  When  asked  if  he  was  being  hurt,  he  assured  me  that 
he  was  not,  but  came  back  with  the  inquiry  as  to  how  soon  the 
operation  would  be  completed.  This  patient  was  quite  willing 
to  ride  back  to  his  bed  on  the  cart  and  lay  heavily  upon  his  pillows 
for  the  remainder  of  the  day,  and  expressed  no  desire  to  sit  up 
until  the  fourth  day.  His  pulse  was  fuller  and  more  bounding 
after  the  operation  and  was  increased  in  rate  some  ten  beats. 

The  problem  is  to  so  operate  that  the  two  patients  last  men- 
tioned shall  experience  no  more  depression  than  the  first  one 
detailed.  There  is  but  little  that  can  be  offered  at  present  which 
will  enable  one  always  to  achieve  the  desired  result.  The  extent 
of  the  operation,  its  location,  the  patient's  general  condition,  his 
mental  attitude  and  general  nervous  state,  and  lastly,  the  drug 
emnloyed  are  all  matters  of  importance. 

The  extent  of  the  operation  naturally  enhances  the  importance 
of  all  the  other  factors  and  therefore  is  difficult  to  consider  as 
a  separate  factor.  Generally  speaking  this  seems  to  be  the  least 


Surgical   Operations  with  Local  Anesthesia  53 

important  factor,  for,  if  the  other  factors  can  be  controlled,  the 
amount  of  tissue  involved  seems  to  make  but  little  difference. 

The  location  of  the  operation  is  of  greater  importance.  The 
neck  is  more  vulnerable  than  the  inguinal  and  perineal  and  anal 
regions,  though  less  difficult  to  operate  upon  painlessly.  The  more 
important  structures  involved  furnishes  an  adequate  explana- 
tion. The  depressing  influences  can  be  avoided  only  by  pre- 
serving as  much  as  possible  the  more  important  structures. 
Thus,  one  may  think  twice  before  ligating  the  external  carotid 
or  cutting  the  pneumogastric  nerve.  The  bloodless  field  secured 
by  the  local  anesthesia  often  makes  preservation  of  important 
structures  possible,  when  they  would  be  sacrificed  if  operating 
under  general  anesthesia. 

The  mental  attitude  of  the  patient  is  of  the  greatest  importance 
and  is  the  factor  most  capable  of  amelioration.  Nervous  patients 
show  the  depression  more  readily  than  those  who  are  composed. 
This  applies  less  to  the  neurotic  than  to  the  apprehensive.  The 
neurotic  may  be  calmed  with  bromides  and  the  preliminary  hyp- 
notic, and  sometimes  by  judicious  advice  to  quit  her  foolishness. 
Those  possessed  by  real  fear  can  be  best  reassured  by  talking 
with  a  patient  who  has  undergone  a  similar  operation.  A  judi- 
cious mingling  of  the  convalescent  with  the  candidate  usually 
secures  the  results.  Of  course,  this  contact  must  be  apparently 
unpremeditated,  but  one  need  not  worry  about  the  results ;  the 
convalescent  will  bring  the  candidate  to  a  proper  state  of  mind. 
Sometimes  a  brief  explanation  of  the  details  of  the  operation  on 
the  part  of  the  surgeon  produces  the  desired  results.  A  quiet, 
expeditious  personnel  in  the  operating  room  is  of  great  import- 
ance. The  talking  should  be  left  to  the  surgeon,  and  if  he  is 
experienced  he  will  confine  his  remarks  to  an  occasional  inquiry 
as  to  the  comfort  of  the  patient.  His  armamentarium  will  be 
confined  to  such  instruments  as  he  actually  needs.  If  the  patient 
notes  that  but  a  few  instruments  have  been  prepared  she  is  very 
apt  to  conclude  that  she  had  an  exaggerated  notion  of  the  gravity 
of  her  operation. 


54  Surgical  Operations  ivith  Local  Anesthesia 

Those  afflicted  with  grave  constitutional  diseases  feel  the 
depressing  influence  of  operation  under  local  anesthesia  as  well 
as  under  general.  Those  in  the  last  stages  of  malignant  disease 
are  particularly  likely  to  feel  the  depressing  effect  of  the  opera- 
tion and  but  little  can  be  done  to  ameliorate  the  condition.  Dia- 
betics too  are  apt  to  be  easily  depressed.  Codein  given  regularly 
for  a  week  before  the  operation  is  of  the  utmost  importance  in 
conjunction,  of  course,  with  the  usual  diatetic  treatment. 

The  drug  employed  is  a  matter  of  much  moment  and  is  perhaps 
the  most  potent  factor.  Novocain  often  produces  a  slight  depres- 
sion before  the  operation  is  begun,  which,  however,  is  quickly 
recovered  from.  I  have  never  seen  even  mildly  alarming  symp- 
toms, nor  have  I  noted  such  in  the  literature.  Nevertheless, 
this  slight  depression  caused  by  novocain  is  suggestive  to  those 
who  have  had  experience  with  cocain.  I  have  never  used  the 
large  doses  employed  by  some.  My  plan  is  to  use  novocain  in 
loose  tissues  where  hemostasis  is  important  and  employ  quinine 
for  the  remainder  of  the  operation.  By  following  this  plan  I 
rarely  find  it  necessary  to  use  more  than  five  grains  of  novocain 
for  any  operation.  However,  a  number  of  operators  have  used 
as  much  as  fifteen  grains  without  serious  results. 

Local  anesthesia  has  a  limited  use  in  preventing  after-pain 
when  used  in  conjunction  with  general  anesthetics.  In  opera- 
tions about  particularly  painful  areas,  quinine  infiltration  very 
materially  lessens  after-pain.  Ford  Rogers  first  proposed  the 
use  of  quinine  for  the  control  of  after-pain  in  hemorrhoids  when 
this  operation  is  performed  as  a  terminal  act  in  more  extensive 
operations  done  under  general  anesthesia.  Used  in  this  manner 
the  method  is  very  useful.  The  same  applies  to  any  painful  area 
where  quinine  can  be  used.  I  employ  it  regularly  when  the 
cautery  is  applied.  When  large  nerves  are  to  be  severed  as  in 
amputations,  it  is  worth  while  to  inject  the  main  nerves  with 
quinine. 

In  the  control  of  shock  when  general  anesthesia  is  used,  local 
anesthesia  has  a  limited  application.  The  chief  shocking  agent 


Surgical  Operations  with  Local  Anesthesia  55 

in  major  operations  unquestionably  is  ether.  Recent  investiga- 
tions by  Sweet  and  Corbett  indicate  that  possibly  the  reduction  of 
the  epinephrin  content  caused  by  ether  may  be  the  cause  of  it. 

Whenever  it  is  possible  to  block  efferent  impulses,  it  is  well  to 
do  so  as  in  major  amputations.  Whether  it  is  the  action  of  a 
large  nerve  or  nerves,  or  the  loss  of  so  large  a  part  of  the  body 
that  makes  these  operations  serious,  is  not  known.  Statistics 
capable  of  making  a  conclusion  possible  are  not  available. 

That  shock  is  the  result  of  the  action  of  painful  impulses  upon 
the  brain,  has  not  been  proven.  Certain  changes  in  the  brain  cells 
have  been  noted  in  association  with  shock,  it  is  true,  but  like 
changes  follow  fatigue  and  even  normal  exercises  of  function 
without  fatigue.  Most  of  these  studies  have  been  concerned  with 
Purkinje's  cells  in  the  cerebellum.  We  do  not  know  what  areas 
of  the  brain  are  concerned  with  the  reception  of  painful  impres- 
sions, but  most  likely  the  cerebellum  does  not  perform  this 
function. 

Even  if  we  grant  this  hypothesis  that  the  organic  changes 
observed  in  the  brain  cells,  as  studied  by  Dolly  and  others  do 
occur,  and  that  we  could  prevent  these  changes  by  blocking  the 
transmission  of  painful  impulses  by  means  of  local  anesthesia, 
we  would  be  as  yet  unable  to  meet  the  indications.  Shocking 
impulses  do  not  arise  from  the  skin,  but  from  the  structures 
lying  deeper.  In  abdominal  operations  it  is  the  adherent  masses 
from  inflammation  or  new  growths  that  are  the  most  likely  to 
produce  shock.  Theoretically  these  impulses  could  be  blocked 
by  reaching  the  rami  communicantes.  Practically,  however, 
blocking  of  these  regions  consume  too  much  time  and  is  too  un- 
certain in  its  results  to  be  of  much  value. 

If  local  and  general  anesthesia  are  to  be  combined,  it  is  best 
to  go  as  far  as  expedient  with  local  anesthesia  and  then  employ 
general  through  the  more  painful  part  of  the  operation.  This 
method  must  be  used  with  very  fine  judgment  lest  more  harm 
than  good  result.  The  operation  under  local  must  not  be  con- 
tinued until  the  patient  has  become  excited  from  pain.  If  this 


56  Surgical  Operations  with  Local  Anesthesia 

state  is  reached  the  amount  of  ether  required  is  likely  to  be 
greater  than  if  general  anesthesia  has  been  used  from  the  begin- 
ning. 

If  the  painful  stage  of  the  operation  is  very  short,  just  a  little 
ether  may  be  given  and  the  operation  may  be  completed  under 
the  local  anesthetic.  If  the  patient  has  been  completely  anes- 
thetized, he  is  apt  to  be  unruly  as  he  wakens  and  thus  hamper  the 
manipulations  of  the  operator.  Unless  there  is  a  direct  contra- 
indication against  ether  in  operations  too  great  to  be  performed 
under  local  anesthesia  alone,  the  entire  operation  had  best  be 
done  under  the  general  anesthetic. 

Where  a  general  anesthetic  must  be  combined  with  local,  gas 
is  a  much  more  valuable  agent  than  is  ether.  This  combination 
is  desirable  in  abdominal  operations.  If  the  abdominal  wall  is 
well  infiltrated  there  will  be  satisfactory  relaxation  of  the  muscles 
when  the  patient  is  under  gas.  The  painful  part  of  the  operation 
may  be  performed  under  gas,  and  when  this  is  completed  the 
patient  is  allowed  to  awaken  and  the  operation  then  completed 
with  local.  Patients  awaken  quickly  from  gas  and  are  amenable 
to  reason  at  once,  and  are  not  dazed  and  unruly  as  they  are  after 
ether  has  been  given. 

As  generally  employed  in  conjunction  with  ether,  local  anes- 
thetics are  improperly  used  and  are  incapable  of  producing 
local  anesthesia.  In  fact  the  hurried  injection  of  the  solution, 
often  with  big  needles,  is  calculated  to  increase  rather  than  limit 
the  afferent  impulses.  If  the  anesthetics  are  to  be  combined,  the 
local  anesthetic  should  be  used  with  the  same  care  as  if  the  opera- 
tion were  to  be  done  under  local  anesthesia  alone.  Unless 
this  is  done  the  whole  procedure  is  a  sham  and  a  pretense. 

Clinical  experience  teaches  that  in  ether  itself  often  is  found 
the  most  potent  agent  in  the  production  of  shock.  Any  means 
that  will  lessen  the  use  of  this  anesthetic  will  lessen  depression 
following  operations.  For  this  reason  local  anesthesia  and  gas 
in  conjection  or  in  sequence,  will  make  operations  more  safe. 

On  the  whole  the  combination  of  local  and  general  anesthesia 


Surgical  Operations  with  Local  Anesthesia  57 

is  not  productive  of  much  good.  A  careful  use  of  a  general  anes- 
thetic, with  the  expeditious  completion  of  the  operation,  will  pro- 
duce less  harm  than  the  delay  incident  to  the  use  of  the  local 
anesthetic  in  conjunction  with  the  general,  in  so  far  as  the  pre- 
vention of  shock  is  concerned. 


CHAPTER  IV 
GENERAL  OPERATIONS 

THE  OPENING  OF  ABSCESSES. — Localized  abscesses  are  eas- 
ily anesthetised  by  freezing  the  surface  or  by  injection  of 
one  of  the  more  easily  diffusible  anesthetics,  such  as  novo- 
cain.  If  the  abscess  is  "ripe"  the  stage  of  hypersensitiveness 
has  passed  and  a  line  may  be  infiltrated  over  its  summit 
by  beginning  at  the  border  in  or  near  the  normal  skin. 
In  more  acutely  inflamed  areas  it  is  best  to  infiltrate,  first,  the 
normal  skin  about  the  base  and  then  the  summit.  If  the  abscess 
is  on  an  extremity,  the  nerves  supplying  the  part  may  be  blocked 
in  their  course.  For  instance,  in  case  of  a  felon  the  nerve  supply- 
ing the  digit  may  be  blocked  at  some  distance  from  the  infected 
area.  Novocain  acts  more  readily,  but  quinine  may  be  used. 
The  latter  has  the  advantage  of  saving  the  after-pain.  The  skin 
over  a  deep-seated  abscess  may  be  entirely  unaffected,  and  cati 
be  anesthetized  as  usual.  Thus,  in  case  of  renal  or  appendiceal 
abscess  the  parietes  are  infiltrated  as  for  any  other  operation. 

It  is  difficult  to  anesthetize  inflamed  tissue  because  the  exu- 
date  interferes  with  free  diffusion  of  the  solution.  On  account 
of  the  extreme  sensitiveness  of  such  tissue  both  to  pressure  and 
to  puncture,  one  should  begin  the  injection  in  the  unaffected  skin. 
If  the  diseased  part  is  so  large  that  this  is  not  practicable,  the 
case  is  not  one  for  local  anesthesia.  When  the  incision  indicated 
can  be  quickly  and  surely  made,  nitrous  oxide  is  sufficient 
but  if  it  is  extensive  and  the  extent  of  the  operation  cannot  with 
certainty  be  foreseen,  ether  will  probably  be  the  best  anesthetic. 
Venous  anesthesia  in  the  region  of  inflammation  can  hardly  be 
regarded  as  other  than  a  measure  of  necessity  to  be  resorted  to 
only  in  the  face  of  distinct  contraindications  to  general  anesthe- 
sia. For  such  cases  nitrous-oxid-oxygen  is  the  anesthetic  of 
choice. 

58 


Surgical   Operations  with  Local  Anesthesia 


59 


Not  only  are  there  great  technical  difficulties  to  be  overcome 
in  treating  suppurative  processes,  but  the  problem  is  complicated 
by  the  disposition  of  the  patient.  Patients  with  chronic  pus 
infections  are  peevish  and  bear  pain  poorly.  Such  difficulties 
may  render  a  general  anesthetic  greatly  to  be  desired  even  in  the 
hands  of  operators  who  are  experienced  in  the  use  of  local  anes- 
thesia. 

THE  REMOVAL  OF  TUMORS. — The  removal  of  benign  tumors  usu- 
ally furnishes  the  first  lesson  for  the  student  of  local  anesthesia. 
The  encapsulated  tumor  demands  little  more  than  a  linear  skin 


Fig.  11.     Showing  the  line  of  infiltration  over  the  summit  of  a  wen. 

injection,  perhaps  with  infiltration  about  the  base.  Adherent  or 
diffuse  malignant  tumors  are  the  final  task  for  the  master  in  the 
use  of  local  anesthesia.  An  operator's  qualification  for  the  sur- 
gery of  such  tumors  under  local  anesthesia,  is  an  accurate  esti- 
mate of  his  own  skill.  It  is  only  when  he  is  satisfied  that  his 
ability  is  equal  to  any  demand,  is  he  warranted  in  under- 
taking the  operation  of  a  malignant  tumor  under  local  anesthesia. 
Yet,  when  this  condition  is  fulfilled,  the  surgeon  may  undertake 
under  local  anesthesia  by  election  many  major  operations  for  the 
removal  of  tumors,  and  almost  any  tumor  operation  may  be 


6o 


Surgical   Operations  with  Local  Anesthesia 


performed,  in  the  face  of  grave  contraindications  to  ether,  by 
this  method.  The  general  problems  involved  can  be  presented 
best  in  the  discussion  of  specific  tumors. 


Fig.  12.     Showing  method  of  edematization  of  the  base  of  a  tumor. 

CIRCUMSCRIBED  BENIGN  TUMORS. — Small  subcutaneous  lipomas, 
wens  and  similar  tumors  may  be  removed  after  infiltrating  a  line 


Fig.  13.     Method  of  injecting  the  skin  about  the  base 
of  a  benign  tumor. 


over  the  summit  (Fig.  u),  with  additional  infiltration  beneath 
the  base  (Fig.  12).  In  larger  tumors  it  is  well  to  circumscribe  an 
ellipse  about  the  base  (Fig.  13),  and  also  to  inject  solution  be- 


Surgical  Operations  with  Local  Anesthesia  61 

neath  them  (Fig.  12).  They  can  then  be  readily  shelled  out 
and  the  redundant  skin  can  be  used  to  cover  the  defect. 

INFILTRATING  LOCALIZED  TUMORS. — In  some  varieties  of  tumors 
the  skin  may  be  involved,  but  the  process  is  yet  localized,  and 
requires  local  excision  only.  Among  these  may  be  mentioned 
papillomas,  nevi,  endotheliomas  and  some  slowly  growing  sar- 
comas. To  remove  these  the  skin  surrounding  the  tumor  and  the 
deeper  tissues  are  infiltrated,  and  the  entire  growth  excised. 
The  elliptical  defect  in  the  skin  can  be  closed  by  sutures  or  by 
skin  grafting. 

In  such  operations  quinine  or  novocain-epinephrin  may  be  used 
with  equal  satisfaction. 

METASTASIZING  TUMORS. — Tumors  predisposed  to  regional  met- 
astasis force  additional  obligat'jns  upon  the  operator.  The  re- 
moval of  the  tumor  itself  is  the  minor  part  of  the  operation.  The 
chief  problem  is  the  removal  of  the  regional  lymph  glands.  Un- 
fortunately many  operators  practice  local  removal  of  known 
malignant  growths  and  thus  invite  recurrences  in  the  adjacent 
lymph  glands. 

In  all  operations  for  malignant  growths  the  technic  when  oper- 
ating under  local  anesthesia  should  be  identical  with  that  em- 
ployed when  operating  under  general  anesthesia.  The  lymph- 
atics should  be  removed  first,  and  the  primary  growth  afterward 
at  a  second  operation  if  necessary.  If  the  local  growth  is  re- 
moved first  and  the  operator  finds  himself  unable  to  complete 
the  operation,  the  patient  being  relieved  of  the  primary  growth 
almost  always  fails  to  return  for  the  removal  of  the  neighboring 
lymph  nodes.  In  case  of  cancer  of  the  lip,  if  the  operator  dis- 
sects out  the  neck  first  the  patient  will  submit  to  a  subsequent 
removal  of  the  tumor  on  the  lip,  but  if  the  lip  tumor  is  removed 
first  he  will  not  return  for  a  dissection  of  the  neck  until  too  late. 

Operations  for  malignant  tumors  resolve  themselves,  therefore, 
into  the  technic  of  lymph  gland  dissection,  and  if  the  surgeon  is 
not  equal  to  this  difficult  procedure  he  should  not  attempt  to 
operate  metastasizing  tumors. 


62  Surgical   Operations  with  Local  Anesthesia 

Inasmuch  as  operations  for  malignant  disease  require  a  dif- 
ferent technic  for  each  region  involved,  they  can  be  considered 
best  in  discussing  the  operative  surgery  of  the  various  parts. 

THE  SEARCH  FOR  FOREIGN  BODIES. — Many  a  beginner  has  failed 
to  find  fragments  of  needles  under  local  anesthesia.  The  trouble 
is  not  with  the  anesthetic,  but  because  of  difficulty  in  the  search. 
No  special  directions  are  needed  for  the  production  of  anesthesia, 
any  of  the  usual  agents  being  efficient.  The  common  error  is  to 
underestimate  the  length  of  the  incision  required.  A  preliminary 
x-ray  plate  is  useful  to  indicate  the  extent  of  infiltration  required, 
as  well  as  to  aid  in  the  subsequent  search  for  the  foreign  body. 
Sometimes  after  the  parts  have  been  anesthetized  the  wire  man- 
drin  which  accompanies  some  of  the  larger  hypodermic  needles 
may  be  made  to  follow  the  channel  traversed  by  the  foreign  body. 
Sometimes,  too,  in  making  the  injection  the  needle  comes  in  con- 
tact with  the  foreign  body  and  thus  aids  in  finding  it  after  the 
incision  is  made. 

SKIN  GRAFTING. — Local  anesthesia  can  be  used  effectively  in 
the  preparation  of  the  bed  as  well  as  in  anesthetizing  the  part 
from  which  the  graft  is  to  be  taken.  Grafts  may,  of  course,  be 
placed  upon  fresh  surfaces  without  previous  preparation.  If  the 
wound  is  covered  by  recent  granulations  the  surface  may  be 
curetted  or  better  still  cut  off  on  the  flat  with  a  knife  after  anes- 
thetizing the  surface  by  compresses  soaked  in  quinine  or  cocain. 
If  granulations  are  not  over  four  weeks  old  and  free  from  incrus- 
tations, exudates  and  notable  infections,  grafts  may  be  placed 
upon  them  without  previous  preparation. 

The  region  from  which  the  skin  is  to  be  removed  is  best  anes- 
thetized by  infiltrating  a  horseshoe  line  with  the  open  end  of  the 
shoe  pointing  toward  the  distal  end  of  the  extremity.  The  infil- 
tration should  be  made  not  only  endermically  but  also  subcu- 
taneously,  in  order  to  block  off  the  nerves.  Sometimes  I  have 
failed  to  secure  anesthesia  promptly  in  this  way.  I  have  then 
resorted  to  subdermic  infiltration  of  the  entire  region  from  which 
the  graft  is  to  be  taken.  It  should  be  emphasized  that  the  injec- 


Surgical  Operations  with  Local  Anesthesia  63 

tion  should  be  made  into  the  subdermic  tissue  and  not  into  the 
skin  itself.  If  the  latter  is  done,  the  healing  of  the  graft  will  be 
materially  interfered  with.  After  anesthesia  is  secured  the  opera- 
tion proceeds  in  the  usual  manner.  In  this  way  grafting  can  be 
done  with  the  least  inconvenience,  and  the  operator  is  often  en- 
couraged to  graft  small  areas  not  large  enough  to  justify  the  use 
of  a  general  anesthetic.  It  is  easily  carried  out  without  any 
assistance,  and  should,  therefore,  commend  itself  to  the  general 
practitioner. 


CHAPTER  V 
OPERATIONS  ON  THE  CRANIUM 

The  cranium  offers  a  particularly  favorable  field  for  opera- 
tions under  local  anesthesia,  because  of  the  constant  location  and 
accessibility  of  the  nerves  supplying  the  scalp.  This  method  is 
practicable  for  all  operations  in  this  region  and  f  >r  certain 
conditions  it  is  mandatory.  It  is  especially  satisfactory  for  the 
excision  of  the  numerous  tumors  which  involve  the  soft  parts, 
and  for  the  treatment  of  injuries  of  the  soft  parts  which  require 
trimming  and  preparation.  Injuries  of  the  bone  may  be  conve- 
niently treated  whether  they  require  the  elevator  or  the  trephine. 
Vigorous  use  of  the  chisel  and  mallet  is  not  well  borne  because  of 
the  unpleasant  jarring,  particularly  if  the  patient  is  suffering  or 
has  previously  suffered  from  headache.  In  severe  accidents  in 
which  the  cranium  is  injured,  together  with  the  mouth,  pharynx, 
throat  or  diaphgram,  the  use  of  local  anesthesia  for  the  manage- 
ment of  the  cranial  injury  is  important  because  of  the  great  dan- 
ger from  pneumonia  after  any  form  of  inhalation  anesthesia. 
The  method  is  particularly  desirable  if  the  head  injury  is  accom- 
panied by  shock  due  to  injury  of  other  parts,  such  as  crushing 
of  the  extremities. 

For  deliberate  operations  for  cranial  and  intra-cranial  disease 
local  anesthesia  is  an  optional  method,  but  is  not  to  be  advised 
if  the  mentality  of  the  patient  has  suffered  because  of  the  dis- 
ease, as  in  post-traumatic  epilepsy  with  associated  mental  weak- 
ness, or  if  the  patient  has  been  a  sufferer  from  severe  headache? 
due  to  increased  tension  from  tumors.  It  is  particularly  likely 
to  succeed  in  exploratory  operations  for  tumors  where  local 
motor  symptoms  are  the  chief  guiding  sign  or  where  decompres- 
sion is  demanded  because  of  developing  choked  disk. 

OPERATIONS  UPON  THE  CRANIAL  SOFT  PARTS. — When  extensive 
operations  are  to  be  done  upon  the  cranial  soft  parts  it  is  conve 

64 


Surgical  Operations  with  Local  Anesthesia  67 

twigs  from  other  than  the  typical  nerve  may  necessitate  infiltra- 
tion of  the  skin.  The  operator  should  distinguish  between  the 
sensation  caused  by  these  twigs  and  pain  from  inadequate  block- 
ing of  the  principal  nerves.  When  anesthesia  has  been  secured 
the  operation  may  proceed  as  under  general  anesthesia.  In  small 
wounds  of  the  scalp  it  is  often  more  convenient  to  pass  the  needle 
from  the  cut  edges  of  the  scalp  when  making  the  infiltration. 
The  danger  of  carrying  infection  into  the  deeper  parts  by  so 
doing  is  theoretical  speculation.  In  a  neglected  wound  less  pain 
will  be  caused  by  infiltrating  an  ellipse  about  it  than  by  entering 
the  skin  from  the  injured  edges  as  recommended  for  fresh 
wounds. 

THE  REMOVAL  OF  TUMORS. — PAPiLLOMAS. — This  term  may  be 
made  to  cover  those  tumors  which  are  a  part  of  the  skin  and  pro- 
ject from  it.  They  can  be  removed  through  the  entire  depth  of 
the  skin  by  infiltrating  an  ellipse  about  the  base  and  injecting  a 
few  drops  beneath.  If  the  operation  be  in  a  very  vascular  area 
such  as  the  scalp,  the  bleeding  from  the  base  or  the  edge  of  skin 
is  often  profuse.  A  deep  suture,  preferably  figure-of-8,  usually 
controls  the  hemorrhage,  this  being  the  only  operation  for  tumors 
in  which  it  is  permissable  to  make  a  coaptation  suture  serve  for 
hemostasis  as  well.  If  quinine  is  used  as  the  anesthetic  the  plac- 
ing of  sutures  thus  tightly  is  not  followed  by  after-pain  as  is 
the  case  if  novocain  is  used.  With  the  papillomas  may  be  classed 
the  melanomas  which  are  usually  somewhat  elevated.  In  remov- 
ing them  a  wide  margin  of  skin  should  be  included  and  in  inject- 
ing the  base  the  needle  should  be  passed  well  beneath  the  tumor 
and  not  into  it.  Other  small  endermic  tumors  may  be  removed 
in  a  like  manner. 

WENS. — Atheromatous  cysts  are  common  upon  the  scalp.  They 
are  sacculated  sebaceous  glands  and  are  free  from  the  skin 
except  at  their  summit.  When  small  they  may  be  exposed  by 
an  incision  over  the  apex  and  the  sac  then  removed.  Larger 
wens  should  be  circumscribed  by  an  elliptical  incision  about  the 
base.  In  the  first  instance  the  skin  is  infiltrated  over  the  summit 


68  Surgical  Operations  with  Local  Anesthesia 

and  from  the  ends  of  this  line  injections  are  made  beneath  the 
tumor.  In  large  growths  an  ellipse  is  injected  surrounding  the 
tumor  and  all  tissue  contiguous  to  and  beneath  the  tumor  is 
abundantly  infiltrated.  This  infiltration  loosens  the  tumor  from 
its  surroundings  and  facilitates  its  removal.  After  hemostasis 
the  skin  is  closed  by  sutures. 

DERMOIDS. — Dermoids  are  found  about  the  great  fontanelle  and 
in  the  temporal  and  mastoid  regions.  The  skin  is  free  but  the 
tumors  are  often  intimately  associated  with  the  periosteum,  so 
that  the  latter  structure  requires  careful  infiltration,  which  may 
be  accomplished  by  passing  the  needle  immediately  over  the 
bone.  A  straight  incision  over  the  summit  or  an  elliptical  in- 
cision as  in  wens,  may  be  employed.  It  is  easy  to  deflect  the  skin 
from  the  tumor,  but  an  elevator  may  be  necessary  in  order  to 
elevate  the  base  of  the  sac  from  the  bone  upon  which  it  lies. 

ENDOTHELIOMA     AND     BENIGN      CYSTIC     EPITHELIOMA. These 

tumors  project  from  the  surface  of  the  scalp  and  do  not  tend  to 
infiltrate  the  depth.  Infiltration  about  the  base  and  between  the 
base  and  the  bone  renders  their  removal  easy.  The  bare  surface 
of  the  skull  which  is  left  may  require  a  preliminary  drilling  of 
the  outer  table.  Usually  fairly  thick  Thiersch's  grafts  are  suc- 
cessful in  filling  in  the  defect,  particularly  if  the  scalp  incision 
is  made  on  the  bevel  and  the  Thiersch  graft  is  allowed  to  extend 
over  the  surface  (Figs.  15  and  16).  The  difficulty  arises  in 
keeping  the  scalp  from  pulling  from  under  the  graft.  Adhesive 
strips  over  vaseline  smeared  gauze  usually  solve  the  problem. 
CARCINOMA. — Malignant  epithelial  growths  are  often  of  a  slow 
development  and  involve  large  surfaces  of  the  scalp.  They  re- 
main free  from  the  bone  for  a  long  time  and  form  metastases 
late.  Such  growths  are  satisfactorily  removed  under  local  anes- 
thesia. If  necessary  the  surface  of  the  bone  may  be  removed 
with  a  chisel.  Skin  grafting  may  be  undertaken  at  once  if  the 
surface  is  favorable  or  the  formation  of  granulations  may  be 
awaited  either  with  or  without  multiple  drilling  of  the  outer 
table  as  the  case  demands. 


Surgical  Operations  ivith  Local  Anesthesia  60 

ANGIOMA. — Blood  vessel  tumors  frequently  occur  upon  the 
scalp  and  offer  ideal  objects  for  operation  under  local  anesthesia 
because  of  the  vascular  constriction  which  can  be  secured  by 
epinephrin.  These  tumors  are  usually  either  venous  cavernomas 
or  mixed  venous  and  arterial  tumors.  The  most  frequent  site 
is  on  the  forehead.  The  best  procedure  for  their  removal  is  as 


Fig.  15.     Incision  about  a  hemangioma.      The  beveled  incision 
furnishes  a  broad  surface  for  the  Thiersch  graft. 


follows :  one  infiltrates  a  line  i  cm.  about  the  base  of  the  tumor 
and  makes  an  incision  down  to  the  bone  three-fifths  of  the  cir- 
cumference of  the  tumor  on  the  side  where  the  scar  will  show 
least.  After  hemorrhage  is  controlled  the  tumor  together  with 


Fig.  16.     The  tumor  shown  in  the  preceding  figure  has  been 
removed  and  a  graft  has  been  placed. 


the  skin  covering  it  is  lifted  from  the  skull,  using  the  two-fifths 
of  the  circumference  not  incised  as  a  hinge.  The  uncut  vessels 
are  now  ligated  beneath  the  hinge.  The  tumor  may  now  be  dis- 
sected from  the  overlying  skin  and  the  flap  so  remaining  is 
returned  to  place  and  sutured.  Large  tumors  may  be  treated  by 
multiple  preliminary  ligation  with  subsequent  excision. 


7o  Surgical  Operations  ivith  Local  Anesthesia 

OPERATIONS  ON  THE  SKULL. — INJURIES. — The  region  of  a  frac- 
ture of  the  skull  is  circumscribed  by  a  line  of  infiltration  from 
which  the  surrounding  soft  parts  are  injected.  In  order  to  de- 
compress, if  an  opening  large  enough  is  already  present  the  loose 
pieces  can  be  pried  up  by  an  elevator  without  further  preliminary 
manipulations.  If  there  is  no  such  opening  a  trephine  opening 
is  made  through  uninjured  bone  as  close  as  possible  to  the  line 
of  fracture.  From  this  opening  the  bone  is  snipped  with  a  Dahl- 
gren  forceps  until  the  dislocated  fragments  can  be  elevated. 
Before  the  bone  is  elevated  it  is  worth  while  to  tell  the  patient 
that  it  is  going  to  "p°P" ;  this  prepares  him  for  the  sensation  of 
lifting  experienced  in  the  brain  when  the  fragment  is  raised. 
The  subsequent  treatment  follows  accepted  principles. 

EXPLORATION  OPERATIONS. — In  the  desired  region,  usually  over 
the  motor  area,  a  horseshoe-shaped  figure  is  infiltrated  one  cm. 
beyond  the  line  in  which  it  is  proposed  to  sever  the  bone.  It  is 
well  to  infiltrate  the  skin  directly  and  likewise  to  edematize  the 
tissue  between  the  bone  and  scalp.  From  this  line  injections  are 
made  beyond  the  line  of  infiltration,  beneath  the  flap  and  beyond 
its  base  (Fig.  17).  An  incision  is  now  made  down  to  the  skull 
in  the  line  infiltrated.  The  scalp  is  elevated  toward  the  center  of 
the  flap  and  slightly  beyond  the  outer  border  of  the  infiltration 
line.  Trephine  openings  are  made  at  two  points  at  the  upper 
margin  of  the  flap  in  the  classical  way.  Before  the  buttons 
loosened  by  the  trephine  are  elevated  the  patient  should  be  told 
that  he  will  hear  a  popping  noise.  An  intelligent  automobile 
engineer  upon  whom  I  operated  compared  this  noise  with  the 
back-firing  of  an  engine,  but  did  not  complain  of  any  pain.  The 
two  trephine  openings  are  united  with  a  Gigli  saw  in  the  usual 
manner.  The  passage  of  the  protecting  director  is  painless  and 
requires  no  anesthesia  after  the  skull  is  opened.  The  patient 
before  mentioned  felt  no  pain  from  the  use  of  the  saw,  but  felt 
the  sensation  of  heat  when  the  saw  became  warm  from  friction, 
and  was  able  to  tell  me  when  it  was  time  to  cool  the  saw.  He  was 
able,  therefore,  to  differentiate  between  the  heat  and  pain  sense. 


Surgical   Operations  ivith  Local  Anesthesia  71 

The  lateral  limbs  of  the  flap  are  made  in  the  usual  way  with  a 
Dahlgren  forceps.  A  large  powerful  instrument  should  be  used 
in  order  that  the  bone  may  be  cut  without  imparting  movements 
to  the  patient's  head.  The  base  of  the  bone  is  broken  in  the  usual 
manner,  the  patient  being  warned  that  there  will  be  a  loud  pop- 


.  17.     Primary  infiltration  line  with  secondary  subdermal  lines  for 
the  typical  cranial  flap  operation. 

ping  noise  when  the  flap  is  raised.  The  patient  above  quoted 
compared  the  noise  to  the  bursting  of  an  automobile  tire.  The 
flap  being  raised  the  operation  may  proceed  in  the  usual  manner. 
The  meninges  and  brain  are  quite  insensitive.  This  is  equally 
true  if  quinine  or  novocain  has  been  used  as  the  anesthetic  for 
the  soft  parts.  My  experience  with  quinine  makes  me  feel  cer- 


72  Surgical   Operations  with  Local  Anesthesia 

tain  that  the  meninges  and  the  brain  are  insensitive  because 
when  the  skull  is  opened  by  endermic  and  subdermic  infiltration 
there  is  no  sensation  of  pain.  The  argument  that  these  structures 
are  made  painless  by  the  diffusion  of  the  anesthetic  is  untenable 
when  quinine  is  used. 

DECOMPRESSION  OPERATIONS. — The  general  procedure  for  both 
occipital  and  temporal  decompression  operations  is  the  same  as 
the  preceding.  The  small  bites  from  a  powerful  Dahlgren  imparts 
less  unpleasant  movements  to  the  head  than  the  usual  rongeur 
forceps,  and  for  that  reason  the  former  is  preferable.  Patients 
who  require  decompression  because  of  headaches  do  not  bear 
local  anesthesia  well.  Even  if  not  suffering  from  headache  at 
the  time  of  operation  they  complain  that  the  sawing  of  the  tre- 
phine causes  a  pain  distributed  over  the  entire  head. 

OPERATIONS     UPON     THE     CRANIAL     CONTENTS. When     lesions 

within  the  brain  are  to  be  dealt  with  it  is  probably  prudent  to 
do  a  two-stage  operation  because  of  the  changes  in  intracranial 
pressure  likely  to  be  produced.  Dural  cysts  and  blood  clots  can 
be  removed  and  even  ventricular  puncture  can  be  made  without 
ill  effect  at  the  time  of  the  primary  operation;  but  so  far  as  I 
know  no  one  has  attempted  the  removal  of  a  tumor  at  the  primary 
operation  when  working  under  local  anesthesia.  Gushing  has 
shown  that  this  can  be  painlessly  done  at  a  second  sitting. 


CHAPTER  VI 
OPERATIONS  ON  THE  FACE  AND  JAWS 

The  most  frequent  operations  about  the  face  and  jaws 
are  those  required  for  malignant  disease.  Nowhere  in  the 
body  do  tumors  bearing  the  same  name  present  such  dif- 
ferent degrees  of  malignancy.  Carcinoma  of  the  face,  for 
instance,  scarcely  is  malignant,  while  carcinoma  of  the  lip 
is  exceedingly  so,  and  sarcoma  of  the  jaw  (epulis)  is  of 
low  malignancy,  while  the  periosteal  osteo-sarcoma  is  malig- 
nant in  the  highest  degree.  Because  of  this  local  anesthe- 
sia has  done  much  mischief  in  malignant  tumors  of  the 
face  by  giving  to  the  inexperienced  a  means  of  tinkering 
with  grave  diseases  which  would  be  beyond  his  field  if  general 
anesthesia  was  required.  This  is  particularly  true  of  carcinoma 
of  the  lip  and  tongue.  The  novice  finds  their  removal  easy  under 
local  anesthesia,  but  leaves  the  glands  undisturbed. 

However,  the  fault  is  with  the  individual  operator  and  not 
with  the  method.  Any  operation  about  the  face  may  be  prop- 
erly done  under  local  anesthesia,  but  it  is  necessary  to  individ- 
ualize. The  life  tendency  of  a  tumor  must  be  predicted  and  the 
operation  planned  accordingly. 

Local  anesthesia  has  the  advantage  of  enabling  one  to  secure 
consent  to  earlier  operation,  permits  more  readily  two-stage 
operations,  makes  dissection  less  bloody  and  frees  the  region  of 
the  operation  from  the  presence  of  the  anesthetist  and  in  a  large 
measure  prevents  deglutition  pneumonia.  That  the  advantages 
are  real  is  attested  to  by  the  fact  that  operators  who  have  once 
familiarized  themselves  with  the  technic  do  not  abandon  the 
method  for  general  anesthesia. 

OPERATIONS  UPON  THE  ORBIT. — Operations  upon  the  orbital 
soft  parts  can  be  done  under  regional  infiltration.  Novocain 
should  always  be  used.  If  the  operation  is  to  be  extensive  the 

73 


74 


Surgical   Operations  with  Local  Anesthesia 


respective  nerves  may,  as  a  preliminary,  be  blocked  within  the 
orbit,  according  to  the  methods  to  be  described  (p.  107).  All 
tumors,  including  those  of  the  bones,  can  be  satisfactorily  re- 
moved in  this  way.  The  operation  of  enucleation  requires  an 
additional  injection  into  the  muscle  sheaths.  Lowenstein  (Klin. 
Monatbl,  f.  Augcn  heilk,  1908,  XLVI,  592),  introduces  the 
needle  at  the  external  border  of  the  orbit,  passes  between  the 


JUt     ',       •Jf.'iJveoJ^.ns  Jftf. 
' 


Fig.  18.     Nerve  supply  of  upper  jaw,  palatal  surface  (Modified  from  Toldt) 

capsule  and  the  eyeball  and  attempts  to  strike  the  optic  nerve 
when  the  needle  has  reached  a  depth  of  4^  cm.  Sidel  (Klin. 
Monatbl,  f.  Augenheilk.,  1911,  XLIX),  edematizes  the  sub- 
junctival  tissue  at  four  points,  injects  the  tissue  behind  the  eye 
and  deposits  i  cc.  of  the  solution  deeply  in  the  retrobulbar  space. 
For  operations  upon  the  frontal  sinus  the  skin  and  periosteum 
must  be  infiltrated  at  the  site  of  the  proposed  incision,  which 


Surgical  Operations  with  Local  Anesthesia 


75 


depends  upon  the  precise  operation  intended.  If  Killian's  opera- 
tion is  to  be  done,  the  infiltration  can  be  made  along  the  lower 
border  of  the  ciliary  ridge  and  down  the  lateral  border  of  the 
nose.  This,  together  with  the  blocking  of  the  ciliary  and  supra- 
orbital  nerves  and  the  use  of  cocain  or  quinine  tampons  within 
the  nose,  enables  the  operator  to  proceed  painlessly. 


up.  denTaJ  n 


Fig.  19.     Nerve  supply  of  the  upper  jaw,  external  surface. 
(Modified  from  Toldt). 


Rhinoplastic  operations  of  the  soft  parts  can  be  done  with 
local  infiltration,  but  when  the  bones  at  the  upper  portion  are 
to  be  dealt  with,  one  must  block  the  ciliary  and  supraorbital 
nerves  and  anesthetize  the  nasal  membrane  by  means  of  tampons. 

NEURAL    ANATOMY    OF   THE    FACE   AND   JAWS.  -  Sensory    imprCS- 

sions   from  the  face  and  jaws  are  carried  by  the  two  lower 


76  Surgical  Operations  with  Local  Anesthesia 

branches  of  the  fifth  cranial  nerve  and  by  branches  of  the  auri- 
cularis  magnus. 

THE  UPPER  JAW. — The  upper  jaw  is  supplied  by  the  second 
branch  of  the  fifth  nerve.  After  its  course  from  the  Gasserian 
ganglion  into  the  pterygo-palatine  fossa,  it  gives  off  the  spheno- 
palatine  and  the  superior  alveolar  branches  and  passes  through 
the  infraorbital  canal  and  foramen  as  the  infraorbital  nerve. 

The  spheno-palatine  branch  traverses  the  palatine  canal.  One 
portion  escapes  to  supply  the  mucous  membrane  of  the  palate 
(Fig.  18).  Another  portion  continuing  along  the  floor  passes 
through  the  foramen  incisivum  to  supply  the  mucous  membrane 
of  the  anterior  portion  of  the  hard  palate  and  gums. 

The  superior  alveolar  branches  are  given  off  from  the  infra- 
orbital  nerve  posterior  to  and  within  the  canal.  They  traverse 
the  superior  maxilla  and  supply  the  teeth  of  the  upper  jaw  after 
freely  anastomosing  with  one  another  (Fig.  19). 

The  infraorbital  divides  into  branches  which  supply  the  skin 
of  the  face,  the  buccal  mucous  membrane,  the  floor  of  the  nose 
and  the  incisor  and  canine  teeth. 

THE  LOWER  JAW. —  (Fig.  20).  The  lower  jaw  is  supplied  by  the 
third  branch  of  the  fifth  nerve.  Originating  in  the  gasserian 
ganglion,  it  escapes  from  the  cranial  cavity  through  the  foramen 
ovale  and  divides  into  a  motor  portion  supplying  the  muscles 
of  mastication,  and  a  sensory  portion,  which  is  of  interest  in 
this  connection,  divides  into  the  auriculo-temporal,  the  lingual 
and  the  inferior  alveolar  branches,  the  last  of  which  supplies 
the  lower  jaw.  It  descends  in  front  of  the  internal  pterygoid 
muscle  to  enter  the  mandibular  canal,  which  it  traverses,  giving 
off  branches  which  supply  the  gums  and  lip.  The  mucous  mem- 
brane on  the  lingual  surface  receives  a  branch  from  the  lingual 
nerve. 

OPERATIONS  ON  THE  SOFT  PARTS  OF  THE  FACE. Because  of  the 

multiplicity  of  origin  of  the  nerve  supply  to  this  region  infiltra- 
tion of  the  soft  parts  about  the  lesion  is  necessary.  This  may 
be  supplemented  by  blocking  the  infraorbital  nerve  at  the  fora- 
men if  the  operation  is  extensive. 


Surgical  Operations  with  Local  Anesthesia  77 

OPERATIONS  UPON   THE  UPPER  JAW. EXTRACTION   OF  TEETH. 

In  the  extraction  of  teeth  pain  is  caused  when  the  tooth  is  torn 
from  the  gum,  when  the  root  is  separated  from  the  periosteum 


Fig.  20.     Nerve  supply  of  the  lower  jaw    showing  inferior  maxillary 
nerve  and  its  branches.     (Modified  from  Toldt). 


fi\ 


Fig.  21.     Direction  of  the  needle         Fig.  22.     Showing  the  relation  of  the 

in  anesthetization  of  the  beveled  edge  of  the  needle  to 

upper  teeth.  the  bone  surface. 

and  when  the  root  nerve  is  ruptured.  Pain  from  the  gums  is 
readily  controlled  by  submucous  injection  with  either  quinine 
or  novocain-epinephrin.  Pain  from  the  initial  prick  of  the  needle 
may  be  prevented  by  the  application  of  cocain  or  of  the  carbol- 


78  Surgical   Operations  with  Local  Anesthesia 

menthol-cocain  mixture  of  Bovain.  With  or  without  one  of  these 
preliminary  measures  the  needle  is  thrust  obliquely  into  the  gum, 
at  a  point  over  the  alveolar  border  of  the  bone  (Fig.  21)  and  not 
at  the  free  edge  of  the  gum.  In  this  way  one  may  anesthetize 
by  diffusion  the  free  edge  of  the  gum  which  comes  in  contact 
with  the  instrument  and  may  also  reach  more  readily  the  perios- 
teum about  the  roots  of  the  teeth. 

A  special  syringe  is  advised  for  the  purpose,  since  the  pressure 
required  is  greater  than  can  be  secured  with  an  ordinary  instru- 
ment. The  needle  is  introduced  just  beneath  the  mucous  mem- 
brane and  a  few  drops  of  the  fluid  are  injected.  The  needle 
should  be  passed  so  that  the  beveled  edge  of  the  point  faces 
toward  the  bone  (Fig.  22).  The  needle  is  then  made  to  penetrate 
the  periosteum  and  the  solution  is  deposited  under  pressure. 
Some  writers  recommend  that  the  fluid  be  deposited  upon  the 
periosteum  and  allowed  to  reach  the  nerve  by  diffusion.  There 
can  be  no  question,  however,  but  that  subperiosteal  infiltration 
gives  more  prompt  and  certain  results.  The  needle  should  be 
introduced  where  the  bone  is  smooth  so  that  it  may  pass  readily 
between  the  bone  and  the  periosteum. 

The  technic  must  vary  somewhat  with  the  region  operated 
upon  because  of  the  differing  thickness  of  the  bone  and  the  cor- 
responding variation  of  time  required  for  the  fluid  to  reach  the 
nerves.  For  instance,  the  thin  plate  of  the  upper  jaw  permits 
diffusion  through  it,  blocking  the  nerves  where  they  enter  the 
roots,  while  in  the  lower  jaw  the  thickness  of  the  bone  is  such 
that  the  nerve  can  be  reached  only  before  it  reaches  the  lingula 
or  at  the  roots  of  the  teeth  by  diffusion  of  fluid  injected  about 
the  necks  of  the  teeth. 

In  addition  to  local  infiltration  nerve  blocking  may  be  resorted 
to,  particularly  when  a  number  of  teeth  are  to  be  operated  on  at 
one  time.  The  posterior  superior  alveolar  and  the  infraorbital 
nerves  are  accessible  for  blocking.  These  nerves  enter  the  alveo- 
lar process  and  supply  the  three  molars.  They  are  blocked  by 
introducing  the  needle  at  the  fold  of  the  buccal  and  alveolar  mu- 


Surgical  Operations  with  Local  Anesthesia  79 

cous  membrane  above  the  second  molar  and  passing  it  along  the 
bone  for  about  an  inch.  One  or  two  cubic  centimeters  of  fluid 
should  be  deposited  here.  In  addition  to  this,  Fischer  recom- 
mends a  submucous  injection  in  front  of  the  first  molar  and  like- 
wise an  injection  over  the  posterior  palatine  foramen.  This 
should  anesthetize  all  the  upper  molar  teeth. 

The  anterior  superior  alveolar  nerves  are  given  off  from  the 
infraorbital  just  before  it  escapes  from  the  canal.  In  order  to 
block  them  the  fluid  should  be  deposited  at  the  foramen,  which 
is  usually  %  mcn  from  the  orbital  border  over  the  first  premolar. 
The  needle  is  entered  at  the  point  where  the  mucous  membrane 
of  the  lip  curves  to  the  gingival  surface.  By  raising  the  lip  the 
needle  can  be  made  to  approach  the  foramen  at  an  angle.  One 
cubic  centimeter  of  fluid  is  deposited  under  as  much  pressure  as 
possible.  The  nerves  at  the  incisive  foramen  must  also  be  in- 
jected. If  the  operation  is  to  approach  the  median  line  the  nerves 
of  the  opposite  side  should  be  injected  in  a  like  manner.  In- 
stead of  injecting  the  infraorbital  foramen  from  the  buccal  sur- 
face it  may  be  reached  more  directly  by  penetrating  the  skin 
directly  over  the  foramen  and  introducing  the  needle  *4  inch 
into  the  canal.  By  this  means  the  nerves  are  more  certainly 
reached.  The  injury  to  the  skin  made  by  the  needle  is  negligible. 

The  anesthetics  of  choice  for  this  region  are  novocain-epine- 
phrin  and  quinine ;  the  former  for  extraction  of  teeth,  the  latter 
for  operations  of  magnitude,  such  as  the  resection  of  the  alveolar 
process. 

TUMORS  OF  THE  ALVEOLAR  PROCESS. — For  the  removal  of  small 
tumors,  such  as  granulomas  or  epulides,  local  infiltration  is  suffi- 
cient. If  the  tumors  are  larger  or  within  the  alveolar  process, 
blocking  of  the  second  branch  at  the  foramen  rotundum,  accord- 
ing to  methods  already  described,  is  necessary.  In  this  case  one 
must  block  the  nerves  in  the  pterygopalatine  fossa  and  infiltrate 
beneath  the  mucosa  along  the  anterior  surface  of  the  upper  jaw. 
Such  submucous  infiltration  may  be  sufficient  in  itself  if  time 
enough  be  allowed,  but  in  this  case  the  mucous  membrane  of 


8o 


Surgical  Operations  with  Local  Anesthesia 


the  antrum  may  remain  sensitive.  One  may  then  inject  directly 
into  the  antrum  through  the  inferior  nasal  fossa.  This  will  not 
be  effective  if  the  antrum  is  infected.  The  usual  instruments 
employed  for  such  operations  may  be  used.  A  biting  forceps  is 
preferable  to  a  chisel. 


Fig.  23.     Line  of  skin  infiltration  in  resection  of  the  upper  jaw. 

INFECTIONS  OF  THE  ANTRUM. — The  external  surface  may  be 
anesthetized  by  infiltrating  fully  between  mucosa  and  bone  and 
in  the  nose  by  local  application  of  quinine  or  cocain.  The 
mucosa  lining  of  the  antrum  still  remains  sensitive  to  a  degree 
depending  upon  the  nature  of  the  pathological  process.  Usually 
the  diffusion  through  the  bone  is  sufficient  to  make  this  pain 


Surgical  Operations  zvith  Local  Anesthesia  81 

negligible.  Any  of  the  standard  operations  may  be  carried  out 
with  satisfaction. 

RESECTION  OF  THE  JAW. — For  this  operation  blocking  at  the 
foramen  rotundum  or  the  Gasserian  ganglion  itself  is  desirable. 
If  the  nerve  is  blocked  within  the  foramen  rotundum  complete 
anesthesia  is  secured.  If  perinural  blocking  through  the  orbit 
is  depended  upon  the  spheno-palatine  had  better  be  blocked 
within  the  spheno-palatine  fossa  because  of  the  uncertainty  of 
reaching  these  nerves  when  perineural  infiltration  of  the  trunk 
of  the  second  branch  is  depended  upon.  In  addition,  the  skin 
must  be  infiltrated  along  the  line  of  incision  (Fig.  23).  Because 
of  the  free  anastomosis  with  the  nerves  of  the  opposite  side,  the 
palatine  nerves  of  the  opposite  side  must  be  infiltrated. 

OPERATIONS  UPON  THE  LOWER  JAW. — Any  of  the  standard 
operations  may  be  done.  With  care  and  experience  these  opera- 
tions become  astonishingly  simple.  Before  attempting  excisions 
of  the  jaw,  I  hesitated  lest  the  mental  effect  of  the  removal  of 
the  jaw  would  prove  a  source  of  shock.  This  anticipation  was 
not  fulfilled.  Patients  bear  the  saw  without  complaint  and  speak 
as  calmly  with  the  tongue  rolling  out  of  the  wound  as  though 
they  were  not  being  subjected  to  any  unusual  experience. 

The  lessened  hemorrhage  and  the  freedom  from  the  interfer- 
ence of  the  anesthetist  makes  local  anesthesia  less  annoying  to  the 
operator  than  general  anesthesia.  The  effect  on  the  patient  is 
most  gratifying.  While  they  may  flatten  out  somewhat  during 
the  course  of  the  operation,  they  are  pretty  sure  to  be  sitting  up 
before  many  hours.  The  advantage  of  this  in  the  prevention  of 
post-operative  pneumonia  will  readily  be  understood  by  those 
who  have  done  much  work  of  this  character. 

EXTRACTION  OF  TEETH. — The  alveolar  process  of  the  lower  jaw 
being  thicker  and  more  dense  than  the  upper,  is  less  easily  anes- 
thetized by  subperiosteal  infiltration.  However,  for  simple  tooth 
extraction  a  careful  subperiosteal  infiltration  (Fig.  24),  and  in- 
filtration about  the  roots  of  the  teeth  (Fig.  25),  relieves  all  the 
pain  except  that  produced  by  the  rupture  of  the  nerve,  and 


82 


Surgical  Operations  with  Local  Anesthesia 


often,  particularly  if  the  fluid  has  been  allowed  to  act  for  some 
minutes,  this  part  of  the  operation  also  may  be  painless.  Novo- 
cain  is  the  anesthetic  of  choice. 

For  extensive  operations  nerve  blocking  should  be  resorted  to. 
The  jaws,  being  supplied  by  nerve  trunks  which  maintain  defi- 
nite anatomic  relations  to  fixed  points,  are  suitable  regions  for 
nerve  blocking.  The  inferior  alveolar  nerve  offers  the  most 
promising  results.  The  lingula,  which  is  usually  palpable  through 


Fig.  24.     The  anesthetic  fluid  is  injected  about  the  neck  of  the  tooth 
so  that  the  diffusion  may  take  place  throughout  the  socket. 

the  mouth,  marks  the  entrance  of  the  nerve  into  the  bone  and 
indicates  its  most  accessible  portion.  The  injection  is  made  at 
a  point  Y-2,  inch  above  the  surface  of  the  molar  teeth,  and  the 
needle  should  penetrate  slightly  more  than  y?.  inch  and  less  than 
24  inch  beyond  the  anterior  border  of  the  ascending  ramus 
(Fig.  26).  This  point  may  be  best  located  by  placing  the  index 
finger  of  the  left  hand  behind  the  last  molar  and  by  resting  the 
tip  on  the  internal  oblique  line.  By  passing  the  needle  through 
the  mucous  membrane,  just  above  the  finger,  and  penetrating 
Y-2.  to  y^  inch  in  depth,  the  nerve  will  be  reached.  It  has  been 
well  emphasized  by  Fischer  (Die  Lokal  Anesthesie  in  der  Zahn 
heilkunde  Fischer,  Berlin,  1911),  that  owing  to  the  obliquity  of 


Surgical  Operations  with  Local  Anesthesia  83 


Fig.  25.     Point  of  injection  for  the  premolar  teeth. 


Fig.  26.     Relation  of  the  tip  of  the  needle  to  the 
lingula  when  the  injection  is  made. 


84          '    Surgical   Operations  zvith  Local  Anesthesia 

the  ascending  ramus  the  needle  must  be  passed  not  in  the  line  of 
the  teeth  but  from  the  canine  tooth  of  the  opposite  side  (Fig.  27). 
Passed  in  this  line  the  needle  tip  comes  to  lie  in  the  vicinity  of 
the  nerve,  where  an  injection  of  2  cubic  centimeters  should  be 
made.  By  injecting  a  few  minims  as  soon  as  the  needle  has 
penetrated  the  mucous  membrane,  and  depositing  a  few  drops 
from  time  to  time,,  the  entrance  of  the  needle  can  be  made  pain- 
less. If  this  technic  is  properly  carried  out  anesthesia  will  be  com- 


Fig.  27.     Showing  the  relation  of  the  syringe  and  needle  to  the  jaw  in 
making  the  injection  for  blocking  the.  nerves  at  the  lingula. 

plete  in  about  20  minutes.  All  the  teeth,  as  far  as  and  including 
the  premolars,  are  anesthetized.  In  order  to  reach  the  teeth 
beyond  this  point  toward  the  median  line  the  nerve  muit  be 
blocked  at  the  opposite  mental  foramen,  which  lies  at  the  base 
of  the  alveolar  process  beneath  the  first  and  second  premolar 
teeth.  To  reach  the  second  premolar  tooth,  the  injection  should 
be  made  below  it  between  the  buccal  and  gingival  mucous  mem- 
brane (Fig.  25). 

TUMORS   or   THE   ALVEOLAR   PROCESS. — Granulomas   and   small 
epulides   can  be  removed  by  local  infiltration.     Larger  tumors 


Surgical  Operations  with  Local  Anesthesia  85 

require  the  blocking  of  the  nerves  at  the  lingula,  and  also  local 
submucous  infiltration  (Fig.  28).  If  the  tumor  is  situated  near 
the  median  line,  the  nerve  of  the  opposite  side  must  be  blocked 
at  the  mental  foramen.  The  necessity  for  infiltrating  the  mucous 
membrane  about  the  tumor  comes  from  the  fact  that  there  is  free 
anastomosis  from  other  nerves  the  exact  source  of  which  may  be 


Fig.  '28.     Submucous  infiltration  for  operation  upon  a  dentigerous  cyst. 

difficult  to  understand.  This  is  no  great  disadvantage,  for  after 
infiltrating  about  the  nerve  trunks  at  the  lingula  some  time  elapses 
before  these  nerves  become  anesthetized,  and  the  operator  may 
employ  this  time  infiltrating  the  mucous  membrane. 

EXCISION    OF   THE   CERVICAL   LYMPH    GLANDS. The   first   Step    ill 

all  operations  for  malignant  disease  about  the  jaws,  tongue, 
mouth  and  lips  must  invariably  be  the  removal  of  the  regional 
lymphatics.  Extensive  gland  infiltrations  in  the  neck  from  malig-- 


86 


Surgical  -Operations  with  Local  Anesthesia 


nant  metastasis  where  soft  tissues  and  vessels  are  matted  together 
are  not  suitable  for  operation  under  local  anesthesia,  and,  of 
course,  removal  by  any  method  is  useless. 

I  have  never  secured  a  permanent  cure  in  carcinoma  of  the 
mouth  or  jaws  in  which  the  cervical  lymph  glands  were  not 


Fig.  29.     Line  of  infiltration  for  the  removal  of  the  cervical  lymph  glands 
preliminary  to  operations  for  carcinoma  of  the  lips. 

removed  at  the  primary  operation  and  later  became  palpable. 
If  the  glands  are  palpable  before  an  operation  has  been  done 
upon  the  primary  lesion  there  is  some  prospect  of  at  least  pro- 
longed relief.  In  lymph  gland  involvement,  following  tumors 
of  the  parotid,  whether  previously  operated  on  or  not,  offers 
a  good  prognosis.  The  chief  use  of  the  removal  of  the 


Surgical  Operations  with  Local  Anesthesia  87 

cervical  lymph  glands,  however,  is  purely  prophylactic.  The 
unaffected  glands  are  small  and  difficult  to  see.  It  is  necessary, 
therefore,  to  remove  all  connective  tissue  within  which  they  may 
lie.  The  tissue  intimately  associated  with  the  internal  jugular 
vein  is  particularly  likely  to  harbor  them,  and  for  this  reason  this 
vessel  should  always  be  removed. 


Fig.  30.     Points  of  infiltration  in  front  of  the  carotid  sheath  and  between  the 
carotid  sheath  and  trachea  in  removal  of  the  cervical  lymph  glands. 

Because  of  the  vessel-constricting  action  of  epinephrin,  this 
agent  associated  with  novocain  should  always  be  used.  The 
vessels  show  up  more  sharply  than  when  using  quinine  or  opera- 
ting under  general  anesthesia,  and  therefore  facilitate  thorough 
work. 

A  convenient  incision  for  gland  extirpation  is  one  beginning 
at  the  point  of  the  chin  and  extending  backward  beneath  the 
border  of  the  jaw  beyond  the  angle.  Joining  this  line  at  about 
its  midpoint  one  infiltrates  a  second  along  the  anterior  border  of 
the  sterno-mastoid  (Fig.  29),  and  through  it  injects  the  deeper 


88  Surgical  Operations  with  Local  Anesthesia 

tissues.  Through  the  horizontal  line  one  infiltrates  the  loose 
tissue  about  the  submaxillary  fossa  and  at  its  posterior  extremity 
the  digastric  fossa  anterior  to  the  sterno-mastoid.  In  this  way 
one  blocks  the  cervical  nerves,  which  are  the  chief  supply  to  the 
lower  part  of  this  region.  The  deep  regions  of  the  neck  can  be 
infiltrated  by  passing  the  needle  behind  the  artery,  as  described 
in  the  operation  for  the  removal  of  the  thyroid  gland.  It  is  easy 
to  locate  the  artery  by  palpation  and  thus  avoid  it.  This  is  best 
done  by  passing  the  needle  behind  the  sterno-mastoid  muscle, 
which  brings  the  needle  behind  the  carotid  sheath  and  avoids  the 
internal  jugular  vein.  No  ill  effects  come  from  the  deposition 
of  the  anesthetic  solution  about  the  pneumogastric  nerve. 

When  a  large  packet  of  glands  are  to  be  removed,  as  in  tuber- 
culosis or  Hodgkin's  disease,  wherein  the  carotid  is  displaced 
outward,  it  may  be  advantageous  to  pass  the  needle  in  front  of 
the  cartoid  sheath  (Fig.  30).  This  has  the  advantage  of  bring- 
ing the  anesthetic  fluid  directly  into  the  field  of  operation.  The 
edema  and  muscular  constriction  so  produced  greatly  facilitates 
dissection.  The  tissue  between  the  gland  packet  and  trachea 
(Fig.  30),  should  be  infiltrated  in  order  to  make  the  patient  less 
sensitive  to  traction  upon  the  trachea.  By  passing  the  needle 
lateralward  and  backward,  the  roots  of  the  cervical  nerves  may 
be  reached. 

If  in  the  course  of  the  operation  for  the  removal  of  lymph 
glands  the  deeper  tissues  are  found  to  be  still  sensitive  when 
exposed,  edematization  by  dilute  solutions  quickly  reduces  the 
sensitiveness.  The  point  most  likely  to  give  rise  to  pain  is 
beneath  the  base  of  the  skull  when  the  jugular  is  ligated  high  up. 
Undue  anxiety  on  the  part  of  the  operator  may  cause  him  to 
include  the  vagus  nerve  in  his  ligature. 

The  dissection  is  commenced  below.  If  the  external  jugular 
is  to  be  removed  it  should  be  isolated  below  and  doubly  ligated. 
Dissection  upward  is  then  easily  and  rapidly  accomplished.  If 
any  pulling  must  be  done  it  should  be  from  below  upward, 
because  tugging  laterally  or  downward  transmits  a  pull  to  the 


Surgical   Operations  i^ith  Local  Anesthesia 


89 


pharynx  and  trachea  and  may  give  the  patient  a  feeling  of  suffo- 
cation. In  fact,  blunt  dissection  should  give  way  to  sharp  dis- 
section, particularly  when  removing  the  submaxillary  glands. 
When  this  dissection  has  been  accomplished,  any  operation  for 
the  removal  of  malignant  tumors  may  follow. 


Fig:-  31.     Line  of  infiltration  for  excision  of  the  jaw. 

Quinine  may  be  advantageously  used  for  the  skin  nitration, 
but  novocain  is  best  for  deep  infiltration. 

EXCISION  OF  THE  JAW. — This  is  required  for  carcinoma  of  the 


90  Surgical  Operations  with  Local  Anesthesia 

alveolar  border  and  for  sarcoma.  Other  tumors  admit  of  con- 
servative operations.  A  skin  incision,  somewhat  modified  from 
that  used  in  the  removal  of  the  cervical  glands,  may  be  used  to 
advantage  (Fig.  31).  It  extends  from  the  clavicle  upwards  along 
the  anterior  border  of  the  sterno-mastoid  but  passes  near  the  par- 
otid instead  of  over  the  mastoid  process.  The  deep  structures  are 
anesthetized  as  for  the  removal  of  the  cervical  glands.  At  the 
level  of  the  hyoid  bone  a  second  line  extends  over  the  point  of 
the  chin.  From  this  line  the  mental  foramen  of  the  opposite 
side  may  be  reached.  This  incision  gives  good  access  to  the 
tongue  and  floor  of  the  mouth,  as  well  as  to  the  jaw. 

It  is  well  to  block  the  nerves  at  the  lingula  before  the  prelimi- 
nary neck  infiltration.  In  addition,  the  mucosa  in  the  floor  of  the 
mouth  must  be  infiltrated.  If  the  cautery  is  to  be  used  for  incis- 
ing the  mucous  membrane,  quinine  should  be  used  for  this  infil- 
tration, because  of  the  long  duration  of  its  effect. 

The  operation  proceeds  in  the  usual  sequence.  When  the  jawr 
has  been  separated  from  the  floor  of  the  mouth  it  may  be  sawed. 
If  the  section  is  made  near  the  median  line  the  nerve  from  the 
opposite  side  should  be  blocked  at  its  exit  from  the  mental  fora- 
men. Section  of  the  bone  is  best  made  with  a  Gigli  saw,  and  the 
bone  should  be  supported  by  a  bone-holding  forceps  in  order  to 
avoid  imparting  unpleasant  movements  to  the  head  of  the  patient 
in  the  process  of  sawing.  The  floor  of  the  mouth  is  repaired  as 
may  please  the  operator. 

If  the  entire  half  of  the  jaw  is  to  be  removed  the  third  branch 
must  be  blocked  at  its  exit  from  the  foramen. 

OPERATIONS  ON  THE  TONGUE. — Limited  lesions,  such  as  cysts, 
can  be  excised  under  local  infiltration.  More  extensive  lesions 
require  blocking  of  the  nerves  at  the  lingula,  or  the  lingual  nerve 
alone,  according  to  the  method  of  Skillern  (Surg.  Gyn.  &  Obs., 
1913,  XVII.,  114).  This  writer  palpates  the  nerve  where  it  lies 
close  to  the  bone  near  the  wisdom  tooth.  If  one  projects  a  line 
from  the  last  molar  tooth  to  the  angle  of  the  mandible,  the  nerve 
crosses  this  line  half  an  inch  below  the  tooth.  It  is  easier  to 
block  the  nerve  here  than  at  the  lingula. 


Surgical  Operations  ^vith  Local  Anesthesia  91 

If  the  operation  will  involve  a  lateral  half  of  the  tongue,  the 
blocking  on  only  one  side  is  sufficient,  but  if  both  sides  or  the  tip 
are  involved,  or  if  the  extent  of  the  disease  is  uncertain,  bilateral 
blocking  is  required.  If  it  is  large  or  situated  near  the  root  of 
the  tongue,  deep  infiltrations  are  required  (Fig.  32).  In  all 
malignant  growths  the  submaxillary  glands  require  removal  and 
the  skin  infiltration  is  required  as  for  typical  excision  of  the  jaw. 


Fig.  32.     Blocking  the  base  of  the  tongue. 

In  addition,  the  periphery  of  the  lesion  may  be  infiltrated  with 
quinine  and  excision  begun  with  the  cautery  knife.  By  the  time 
this  is  completed,  effective  blocking  will  have  taken  place  in 
other  regions. 

The  most  important  recent  advance  in  the  treatment  of  tumors 
of  the  tongue  is  that  proposed  by  Bloodgood.  He  blocks  out  the 
neck  at  the  first  operation  and  allows  this  to  heal  before  opening 
into  the  month  for  the  actual  removal  of  the  tumor  at  a  second 


92  Surgical  Operations  with  Local  Anesthesia 

sitting.  This  avoids  infection  of  the  large  wound  of  the  neck  by 
secretions  from  the  mouth.  This  plan  of  operation  is  particularly 
suited  to  operations  under  local  anesthesia. 

TUMORS  OF  THE  FLOOR  OF  THE  MOUTH. — Ranulas  and  other 
benign  tumors  may  be  removed  by  local  infiltration.  Removal 
of  a  malignant  lesion,  though  small,  should  be  preceded  by  block- 
ing at  the  lingula.  Though  the  growth  itself  can  be  satisfac- 
torily removed  by  infiltration,  if  the  cautery  is  used  the  trans- 
mitted heat  to  the  tongue  and  jaw  is  unpleasant  or  even  painful 
to  the  patient,  unless  the  nerve  has  been  blocked.  In  these  cases, 
likewise,  one  must  remove  the  cervical  lymph  glands. 

The  location  of  tumors  at  the  floor  of  the  mouth  is  such  that 
metastasis  may  take  place  on  either  side  of  the  neck.  In  that 
event  the  neck  dissection  must  be  made  on  both  sides  of  the 
median  line.  For  this  purpose  a  collar  incision  is  useful.  A  line 
below  the  edge  of  the  jaw  is  infiltrated  from  sterno-mastoid  to 
sterno-mastoid.  In  this  manner  the  upper  lymph  nodes  on  both 
sides  can  be  removed.  This  having  been  accomplished,  the 
primary  tumor  may  be  severed,  preferably  by  the  cautery  knife, 
after  a  preliminary  use  of  quinine. 

TUMORS  OF  THE  BUCCAL  SOFT  PARTS. — Tumors  of  the  cheek  and 
lip  can  be  removed  by  local  infiltration,  whether  malignant  or 
benign.  The  removal  of  the  cervical  lymph  glands  is  necessary 
in  all  cases.  The  extent  to  which  the  glands  must  be  removed 
depends  on  the  size  and  location  of  the  tumor.  Small  tumors 
situated  near  one  angle  may  be  preceded  by  the  dissection  of  one 
side  only.  If  large,  or  near  the  median  line,  both  sides  must  be 
cleaned  out.  When  the  tissue  of  the  lip  requiring  removal  is  at 
all  extensive  it  is  advantageous  to  remove  the  glands  as  a  pre- 
liminary operation  and  complete  the  operation  after  healing  of 
the  neck  wound  has  taken  place. 


CHAPTER  VII 
OPERATIONS  ON  THE  EAR  AND  MASTOID 

The  external  ear  and  auditory  organs  have  such  a  complex 
nerve  supply  that  local  infiltration  only  can  be  employed.  The 
external  ear  is  supplied  by  the  auricularis  magnus  and  the  auri- 
culo-temporal  chiefly.  The  latter  nerve  also  supplies  the  skin 
and  mucous  membrane  of  the  external  auditory  canal.  The 
organs  of  hearing  are  supplied  by  the  auricular  branch  of  the 
vagus.  The  middle  ear  and  the  Eustachian  tube  by  the  tympanic 
branch  of  the  glosso-pharyngeal.  The  mastoid  cells  are  supplied 
by  the  mandibular  nerves  through  the  spinosus. 

FURUNCULOSIS  OF  THE  EXTERNAL  MEATUS. — This  exceedingly 
painful  affection  is  difficult  to  anesthetize,  but  the  following 
methods  employed  for  the  tympanic  membrane  give  at  least  par- 
tial results.  Complete  anesthesia  may  be  secured  by  beginning 
the  infiltration  in  the  unaffected  skin  at  the  periphery  of  the 
affection  and  gradually  circumscribing  it.  The  greatest  gentle- 
ness is  necessary  in  order  to  avoid  pressure  pain  from  the  fluid 
before  anesthesia  takes  place.  Cocain  is  the  most  effective  for 
this  operation. 

PARACENTESIS. — Various  means  have  been  employed  to  lessen 
the  pain  of  this  operation  on  the  drum  membrane.  Most  of  the 
solutions  used  for  this  purpose  contain  carbolic  acid  and  cocain. 
The  one  recommended  by  Hechinger  is  as  follows : 

Acid  Carbolic  95  gr.  vii 

Cocain 

Menthol             aa  gr.  xxx 

Alcohol  dr.  iss 

A  bit  of  cotton  is  saturated  with  this  solution  and  pressed 

93 


94  Surgical  Operations  with  Local  Anesthesia 

against  the  tympanic  membrane  for  a  few  minutes.    Bonain  uses 
an  even  stronger  solution  of  carbolic  acid  as  follows : 

Phenol  chrystals 

Menthol 

Cocain  aa         i   gram 

To  this  may  be  added  several  drops  of  epinephrin. 

Usually  no  attempt  at  injection  is  worth  while  since  the  opera- 
tion of  incising  the  membrane  is  no  more  painful  than  the  injec- 
tions used  to  produce  anesthesia. 

THE  MASTOID  OPERATIONS. — Operations  upon  the  mastoid  are 
not  infrequently  required  as  emergency  operations  in  the  course 
of  general  diseases,  notably  scarlet  fever,  typhoid  and  respiratory 
diseases.  My  own  experience  in  this  operation  has  been  limited 
to  those  cases  in  which  a  general  anesthetic  was  contraindicated 
or  when  it  was  necessary  to  treat  ambulant  patients.  Kulen- 
kampff  advises  against  the  use  of  local  anesthesia  in  acute  cases. 
My  first  patient  was  such  a  one  operated  in  1903  in  a  case  of  mas- 
toiditis  following  typhoid  fever.  I  have  since  repeated  the  ex- 
perience in  a  number  of  cases,  and  I  am  led  to  believe  in  conse- 
quence of  this  experience  that  it  is  in  just  such  cases  that  local 
anesthesia  finds  its  most  gratifying  field. 

When  simple  palliative  drainage  is  desired  the  preliminary 
infiltration  need  not  be  elaborate.  A  simple  line  of  infiltration 
over  the  most  prominent  part  of  the  mastoid,  followed  by  infil- 
tration of  the  deeper  parts  from  this  primary  line,  permits  a 
linear  incision  through  the  soft  parts  and  an  adequate  opening 
of  the  cells  for  the  purpose  of  drainage. 

For  the  radical  mastoid  operation  a  more  elaborate  anesthet- 
ization is  required.  The  following  plan  has  given  me  good  ser- 
vice :  beginning  over  the  tip  of  the  mastoid,  a  curved  line  is 
infiltrated,  extending  from  the  point  of  beginning  to  a  point 
above  the  meatus.  This  line  may  be  half  an  inch  or  more 


Surgical  Operations  with  Local  Anesthesia 


95 


from  the  ear  (Fig.  33).  From  the  primary  line  the  deeper  parts 
are  infiltrated  by  passing  the  needle  forwards  and  backwards. 
First,  that  below  the  skin  infiltration  is  injected,  and  then  the 
tissue  on  either  side  of  this  line  (Fig.  33).  Braun  has  shown  that 
attempts  at  injection  beneath  the  periosteum  are  unnecessary 
since  the  periosteum,  together  with  the  bone  and  cells,  receive 
their  nerve  supply  via  the  soft  parts  and  are,  therefore,  effectually 
anesthetized  by  infiltration  of  the  soft  parts. 


Fig.  33.     The  rings  indicate  the  endermic  infiltration  and  the  arrows  the  direction 

of  the  deep  periosteal  infiltration  in  the  radical  mastoid  operation.     The 

x  indicates  the  point  of  exit  of  the  facial  nerve. 

From  the  point  of  beginning  a  line  is  now  infiltrated  in  front 
of  the  ear  to  the  point  of  termination  of  the  line  previously  infil- 
trated back  of  the  ear. 

The  skin  of  the  meatus  is  now  infiltrated  by  passing  the  needle 
behind  the  ear  between  the  skin  and  the  cartilaginous  canal,  and 
as  much  farther  as  possible  (Fig.  34).  Care  must  be  taken  lest 
the  needle  puncture  the  thin  skin  lining  the  meatus  (Fig.  35). 


96  Surgical    Operations  with   Local  Anesthesia 


Hg.  .'54.     Points  of  deep  infiltration  into  the  auditory  canal. 


Drum 


Fig.  3o.     Cross-section  of  the  auditory  canal  showing  the  passage  of  the 
needle  between  the  bone  and  the  soft  parts. 


Surgical  Operations  with  Local  Anesthesia 


97 


This  error  is  made  manifest  by  the  escape  of  the  fluid  out  of 
the  external  ear.  By  care  the  needle  can  be  made  to  follow  the 
desired  plane  for  an  inch  or  more. 

From  the  auditory  canal  an  additional  injection  is  now  made 
(Fig.  36)  according  to  the  suggestion  of  Neumann.  The  needle 
passes  between  the  lining  of  the  canal  and  the  bone.  By  employ- 
ing gentle  pressure,  i  or  2  cc.  of  the  anesthetic  fluid  can  be 


Fig.  36.     Neumanns  method  of  anesthetizing  the  tympanum. 

made  to  diffuse  in  this  plane  and  reach  as  far  as  the  tympanum. 
It  is  imperative  to  employ  for  this  purpose  a  syringe  of  small 
barrel  calibre  in  order  that  a  slow  gentle  expulsion  of  fluid  will 
be  possible. 

By  the  time  the  injections  have  been  completed  the  infiltration 
over  the  mastoid  will  have  produced  an  effective  anesthesia  and 
the  operation  may  be  proceeded  with  without  delay.  Any  opera- 
tion may  be  done.  The  bloodless  field  assured  by  the  epinephrin 
facilitates  the  operation  very  much. 


98  Surgical  Operations  with  Local  Anesthesia 

Kulenkampf  (Beitr.  z.  klin.  Chir.,  1913,  LXXXIII,  446)  ad- 
vises against  the  use  of  local  anesthesia  in  sinus  thrombosis,  or 
temporal  abscess.  I  have  found  no  contraindications  in  these 
diseases.  In  fact,  it  is  in  just  these  cases  that  one  is  often  most 
anxious  to  avoid  inhalation  anesthesia. 

Of  course,  the  increased  extent  of  operation  demanded  by 
these  operations  must  be  anticipated  by  a  corresponding  extent 
of  primary  infiltration.  If  the  sinus  is  to  be  opened,  care  must 
be  taken  that  a  sudden  gush  of  blood  does  not  cover  the  face  of 
the  patient  and  frighten  him.  In  searching  for  temporal  abscess 
the  trephine  may  sometimes  be  used  to  replace  the  chisel.  The 
jarring  of  the  chisel  is  most  likely  to  be  annoying  to  the  patient. 
This  may  be  lessened  or  obviated  by  using  sharp  instruments 
and  proceeding  slowly  and  making  the  cuts  as  obliquely  as  possi- 
ble. A  water  bag  makes  a  more  comfortable  pillow  than  a  sand 
bag  or  blanket. 


CHAPTER  VIII 
OPERATIONS  ON  THE  GASSERIAN  GANGLION  AND  THE  TRIFACIAL 

THE  GASSERIAN  GANGLION. — This  ganglion  was  removed  by 
Krause  under  local  anesthesia,  (Centralbl  f.  Chir.,  1912,  XXXIX, 
385).  He  injected  50  cc.  of  novocain-epinephrin  solution  at  the 
upper  and  lower  borders  of  the  zygomatic  arch  and  at  both  its 
extremities,  first  subcutaneously  and  then  subperiosteally.  From 
the  midpoint  of  the  arch  he  then  infiltrated  the  entire  area  in- 
cluding in  the  flap  ordinarily  used  in  this  operation,  injecting  both 
subcutaneously  and  subperiosteally  The  temporal  fossa  was  infil- 
trated by  passing  the  needle  into  this  region  through  the  mouth 
at  the  level  of  the  temporal  process  of  the  mandible.  There  was 
some  pain  when  the  dura  was  raised  from  the  base  of  the  skull. 
As  soon  as  the  middle  meningeal  artery  was  exposed  the  dura 
at  the  base  was  infiltrated  with  2  cc.  in  front,  at  the  middle  and 
behind  in  such  a  manner  that  the  roots  of  divisions  II  and  III 
were  injected.  There  was  some  pain  when  the  ganglion  was 
shelled  from  its  bed  and  the  roots  severed. 

I  have  performed  this  operation  in  but  a  single  case.  Krause's 
technic  was  followed  in  the  main.  I  made  no  injections  through 
the  mouth,  but  injected  about  the  II  and  III  branches  from  the 
temple.  There  was  considerable  pain  when  the  dura  was  ele- 
vated from  the  base  of  the  skull.  The  ganglion  was  injected  as 
soon  as  exposed.  This  was  followed  by  vomiting.  In  order  to 
facilitate  access,  I  resected  the  zygomatic  arch  after  the  method 
of  Lexer.  This  patient  had  previously  been  operated  on  and  a 
considerable  scar  was  situated  directly  over  the  arch  and  a 
resection  of  the  arch  was  deemed  the  easiest  way  to  get  the  scar 
out  of  the  way  of  the  newly- formed  flap. 

Except  for  the  pain  produced  when  the  dura  was  separated, 
and  the  nausea  that  followed  injection  directly  into  the  ganglion, 
the  operation  was  entirely  satisfactory.  In  my  next  operation  I 

99 


ioo  Surgical  Operations  with  Local  Anesthesia 

shall  inject  the  ganglion  through  the  cheek  as  a  preliminary  step. 
This  should  effectually  anesthetize  the  ganglion  and  control  the 
pain  when  it  is  twisted  out. 

DIRECT  INJECTION  OF  THE  GASSERIAN  GANGLION. The  injec- 
tion of  the  Gasserian  ganglion  itself  offers  greater  possibilities 
of  usefulness  than  any  other  nerve  blocking  operation.  Attempts 
at  this  procedure  were  made  by  Schlosser  (Verhandl  d.  Kong.  f. 
innere  Med.,  Wiesbaden,  1907,  XXIV,  49).  Ostwalt  (Berlin, 
kiln.  Woch.  1906,  XLIII,  10),  and  Harris  and  Offerhaus  (Arch, 
f.  kiln.  Chir.,  1910,  XCII,  47;  Deutsch  med.-  Woch.,  1910, 
XXXVI,  1527),  all  of  whom  reached  the  ganglion  through  the 
mouth,  which  is  obviously  objectionable  because  of  the  danger 
of  infection. 

Hartel  (Arch.  f.  klin.  Chir.,  1913,  C,  193)  perfected  a  method 
whereby  the  needle  is  made  to  traverse  the  cheek  without  en- 
tering the  buccal  cavity.  The  same  author  likewise  carefully 
studied  the  anatomic  relations  of  the  ganglion,  and  pointed  out 
many  difficulties  that  may  be  encountered,  and  indicated  a  few 
dangers  that  must  be  avoided.  This  operation  may  be  consid- 
ered to  be  the  standard. 

The  ganglion  lies  in  Meckels'  fossa  in  the  superior  lateral 
plane  of  the  petrous  portion  of  the  temporal  bone.  Internal  to 
it  is  the  cavernous  sinus  and  the  internal  cartoid  artery.  It  is  ap- 
proached for  blocking  through  the  foramen  ovale.  Viewed  from 
the  base  of  the  skull  from  which  direction  the  needle  must  ap- 
proach it,  it  is  seen  at  the  base  of  the  lesser  wing  of  the  sphe- 
noid, and  at  the  posterior  border  of  the  external  pterygoid  plate 
(Fig.  37).  Internal  to  it  is  the  foramen  lacerum  medium  and 
behind  it  is  the  spina  angularis,  containing  the  foramen  spinosum 
for  the  transmission  of  the  middle  meningeal  artery. 

There  is  considerable  variation  in  size  and  shape  of  the  for- 
amen. Hartel  found  a  variation  in  length  from  5  to  1 1  mm. 
with  an  average  of  7  mm.  and  a  width  of  2  to  8  mm.  with  an 
average  of  4  mm.  Sometimes  the  foramen  is  continuous  with 
the  foramen  spinosum  and  with  the  foramen  lacerum  medium. 
Sometimes  the  foramen  is  multiple. 


Suryical  Operations  with  Local  Anesthesia 


101 


The  foramen  presents  a  canal  nearly  a  centimeter  long  ex- 
tending from  below  upwards,  backwards  and  inwards.  The 
planum  infratemporale  is  a  smooth  surface  which  slopes  gradu- 
ally toward  the  foramen,  and  furnishes  a  guide  to  the  needle 
which  approaches  it  at  an  acute  angle.  This  plane,  bounded 


Fig.  ••57.     The  needle  passed  from  the  second  molar  tooth  into  the  foramen. 
(Adopted  from  Spalteholtz). 

behind  by  the  spina  angularis  and  medially  by  the  external  plate 
of  the  pterygoid  process,  defines  the  limits  within  which  the 
needle  must  search  for  the  foramen. 

If  the  needle  enters  the  cheek  so  that  it  comes  to  lie  midway 
between  the  second  molar  tooth  and  the  malar  bone  (Fig.  5/), 


IO2 


Surgical  Operations  with  Local  Anesthesia 


and  is  thrust  along  a  line  to  a  point  midway  between  the  occi- 
pital and  parietal  fontanelles  in  the  midline  (Fig.  38),  it  will 
enter  at  the  front  of  the  foramen  or  will  strike  the  smooth  sur- 
face of  the  bone  anterior  to  it.  Should  the  needle  strike  the  bone 


Fig.  38.     a.  Needle  is  passed  into  the  ganglion  through  the  foramen  ovale. 
b.  The  needle  reaches  the  ganglion  hy  way  of  the  foramen  ovale. 

the  foramen  is  almost  certain  to  be  farther  posterior,  and  can  be 
entered  by  advancing  the  point  of  the  needle  along  the  bone. 
This  is  accomplished  by  elevating  the  distal  end  of  the  needle. 
This  has  the  effect  of  depressing  the  point  and  bringing  it  into 
the  foramen  (Fig.  39). 


Surgical  Operations  i^'itli  Local  Anesthesia 


103 


Hartel  introduces  the  needle  into  the  cheek  3  cm.  and  back  of 
the  angle  of  the  mouth  at  a  point  previously  anesthetized.  Viewing 
the  patient  from  the  front,  the  needle  passes  in  a  plane  which 
bisects  the  pupil  on  the  side  being  operated  upon  (Fig.  40). 


. 


Fig.  39.     Position  of  the  needle  when  the  foramen  is  not  struck  when  passed 
in  the  line  of  the  second  molar  tooth. 


Viewing  the  patient  from  the  side,  the  needle  is  passed  along  a 
plane,  which  bisects  the  auricular  tubercle  (Fig.  41).  This 
brings  the  point  of  the  needle  to  the  planum  infratemporale  and 
thence  to  the  foramen.  If  the  spina  angularis  is  struck  it  will 


104 


Surgical  Operations  with  Local  Anesthesia 


be  perceived  by  its  rough  surface,  and  the  needle  must  then  be 
directed  farther  upward. 

A  method  quite  as  accurate  and  more  simple  is  to  mark  the 
parietal  eminence  with  the  thumb  and  the  external  occipital  pro- 
tuberance with  the  second  finger.  The  index  finger  marks  a 
point  midway  between  these  two,  which  marks  a  point  2  or  3 


Fig.  40.     Entered  at  a  point  3  cm.  back  of  the  angle  of  the  mouth  and  passes 
in  a  plane  that  bisects  the  pupil  (Hartel). 

cm.  above  the  posterior  fontanelle.  The  needle  grasped  in  the 
free  hand  enters  the  cheek  opposite  the  second  upper  molar  and 
is  passed  directly  toward  the  index  finger  of  the  other  hand  (Fig. 
42).  If  this  misses  the  foramen  the  point  of  the  needle  is  too 
far  medial  and  must  be  directed  lateralward,  and  it  may  be  too 
far  posterior  and  must  be  directed  more  anterior. 


Surgical  Operations  with  Local  Anesthesia 


105 


By  this  method  the  operator  soon  learns  to  strike  the  foramen 
with  astonishing  accuracy. 

When  the  needle  has  entered  the  foramen  it  should  be  thrust 
i  to  1 5/2  cm.  farther  and  the  solution  deposited.  Hartel  has 
found  that  the  distance  between  the  upper  border  of  the  petrous 
portion  of  the  temporal  bone  and  the  lower  posterior  portion  of 
the  foramen  varies  between  1.4  cm.  and  2.3  cm.  The  needle 


H'ig.  41.     Observed  from  the  side  the  needle  passes  in  a  plane  that 
bisects  the  auricular  tubercle  (Hartel). 

should  be  passed  only  to  the  minimum  distance.  If  it  goes  too 
far  it  may  puncture  the  posterior  petrosal  sinus  or  the  cysterna 
pontis,  in  which  case  their  respective  contents  will  escape 
through  the  needle. 

Two  cc.  of  one  per  cent,  novocain-epinephrin  solution  are  in- 
jected into  the  ganglion.  If  injected  too  rapidly  vertigo  and 
nausea  or  even  vomiting  may  take  place.  This  soon  passes  off. 
Anesthesia  in  the  region  supplied  by  all  of  the  branches  comes 
on  at  once  and  lasts  two  or  three  hours. 


io6 


Surgical  Operations  with  Local  Anesthesia 


This  method  of  approach  has  been  employed  for  the  injection 
of  alcohol  in  neuralgia.  Injection  of  alcohol  directly  into  the 
ganglion  is  sometimes  followed  by  vertigo  and  vomiting,  as  is 
true  of  novocain  and  epinephrm. 

OPERATIONS    ON    THE    FIRST    BRANCH    OF    THE    FIFTH     NERVE. — 

This  branch  supplies  the  contents  of  the  orbit  and  the  region 


*s.  k  £*l      ^\ 


s 


Fig.  42.     The  thumb  marks  the  parietal  eminence  and  the  second  finger  the  external  occipital  pro- 
tuberance.    The  tip  of  the  index  finger  lies  midway  between  these  two  points.     The  needle 
entering  over  the  second  molar  tooth  is  directed  at  the  tip  of  the  index  finger. 

about  it.  It  passes  along  the  lateral  wall  of  the  cavernous  sinus 
and  enters  the  orbit  through  the  sphenoidal  fissure,  immediately 
after  dividing  into  its  three  branches.  Of  these  the  lachrymal 
supplies  the  lids  and  the  conjunctiva  of  the  outer  part  of  the  eye 
and  the  skin  of  the  forehead ;  the  frontal  nerve  passes  along  the 
roof  of  the  orbit  and  out  through  the  supraorbital  notch  and  sup- 
plies the  skin  of  the  forehead ;  and  the  naso-ciliary  supplies  the 


Surgical  Operations  with  Local  Anesthesia 


107 


mucous  membrane  and  the  skin  of  the  upper  part  of  the  nose, 
after  passing  through  the  anterior  ethmoidal  foramen  and  the 
ethmoid  plate.  These  branches  may  be  effectually  blocked  either 
by  injecting  the  ganglion  itself  or  by  injections  outside  of  Tenon's 
capsule.  The  latter  is  the  simpler  method  for  the  beginner.  By 
following  the  bony  plate  of  the  orbit,  injury  to  the  orbital  con- 


Fig.  4:!.     Needle  passed  for  blocking  the  nerves  within  the  orbit. 
(Redrawn  from  Braun). 

tents  need  not  be  feared.  Braun  injects  from  two  points. 
First,  he  introduces  the  needle  at  the  external  border  of  the  orbit 
(Fig.  43  and  Fig.  44),  and  passes  it  along  the  bone  3^  to  4  cm. 
when  the  needle  should  be  in  the  region  of  the  orbital  sinus.  Ten 
cc.  of  novocain  solution  are  deposited  here.  The  lachrymal  and 
supraorbital  branches  are  blocked  by  this  injection.  The  second 


io8 


Surgical  Operations  with  Local  Anesthesia 


point  of  injection  is  half  an  inch  above  the  inner  canthus  of  the 
eye.  The  point  of  the  needle  is  made  to  follow  the  bone  for  4  or 
5  cm.  Here  5  cc.  of  the  solution  are  deposited.  Peuckert  recom- 
mends that  the  needle  be  passed  3  cm.  deep.  This  depth  is  to 


Fig.  44.     a.  Needle  passed  into  the  Gasserian  ganglion  by  the  orbital  route,     b.  Passed  through 

the  foramen  ovale  from  the  cheek,     c.  Needle  passed  for  blocking  the  ethmoidal  nerves. 

d.  The  same  for  blocking  the  frontal  and  lachrymal  nerves  (Hartel). 

be  recommended  in  operations  upon  the  appendages  of  the  eye, 
but  for  resection  of  the  supraorbital  nerve  the  depth  suggested 
by  Braun  is  the  more  certain. 

RESECTION    OF    THE    SUPRAORBITAL    NERVE. — This    nerve    IS    the 

only  branch  of  the  first  division  which  is  attacked  surgically  in 


Surgical  Operations  with  Local  Anesthesia 


109 


tic  douloureux.  It  is  reached  through  an  incision  along  the  orbital 
border  after  blocking  the  nerve  within  the  orbit  as  above  de- 
scribed. The  orbital  contents  are  pressed  downward  with  a 
spatula  and  the  nerve  exposed.  If  a  true  foramen  exists  it  is 


Fig.  45.     Needle  passed  through  the  orbit  to  reach  the  foramen  rotundum. 

converted  into  a  notch  and  the  nerve  loosened  as  far  back  as  pos- 
sible. Should  any  sensation  remain  in  the  nerve  it  may  be  di- 
rectly injected  in  its  course.  The  nerve  should  be  cut  off  as 
far  back  as  possible  and  the  peripheral  portion  twisted  out  as  far 
as  possible.  The  most  effective  way  to  secure  a  severance  far 
back  is  to  use  a  nasal  snare  as  recommended  for  the  second 


no  Surgical  Operations  with  Local  Anesthesia 

branch.  This  usually  secures  a  longer  piece  of  nerve  than  if 
twisting  is  depended  upon  as  recommended  by  Thiersch. 

OPERATIONS  UPON  THE  SECOND  BRANCH. — The  main  trunk  of 
this  nerve  can  be  blocked  at  its  exit  from  the  foramen  rotundum. 
This  may  be  accomplished  either  by  passing  beneath  the  malar 
bone  through  the  masseter,  or  by  passing  through  the  orbit.  In 
the  former  case  the  needle  passes  beneath  the  malar  bone  at  about 
its  middle  and  extends  upward  and  backward  at  an  angle  of 
about  25  degrees.  After  passing  the  masseter  muscle  the  needle 
may  strike  the  superior  maxillary  bone.  The  posterior  surface 
of  this  bone  is  then  followed  with  the  needle  until  it  glides  over 
the  rounded  posterior  border,  when  it  is  passed  2  cm.  deeper.  If 
the  needle  is  directed  too  far  back  it  will  strike  the  lesser  wing  of 
the  sphenoid.  In  that  event  the  needle  must  be  directed  farther 
forward  until  this  obstruction  is  passed.  The  needle  will  then 
freely  pass  deeper,  and  should  reach  the  nerve  at  a  depth  of  5 
or  6  cm.  Upon  contact,  the  patient  will  feel  pain  in  the  region 
supplied  by  the  nerve.  An  actual  puncture  of  the  nerve  is  not 
necessary  for  the  success  of  the  anesthesia,  though  when  this  is 
achieved  the  effect  is  more  quick  and  certain.  Braun  recom- 
mends that  5  cc.  of  a  2  per  cent,  novocain-epinephrin  solution 
be  deposited  in  this  region.  While  the  needle  is  being  introduced 
several  cc.  may  be  deposited  with  advantage  along  the  tract. 

The  orbital  route  is  recommended  by  Payr  {Arch.  f.  klin  .Chir. 
1903,  LXXII,  284),  and  Bockenheimer.  The  needle  enters  the 
external  inferior  angle  of  the  orbit  and  is  passed  downward, 
backward  and  inward  at  an  angle  of  25  degrees  (Fig.  a,  44  and 
Fig-  45)-  The  point  of  the  needle  follows  the  floor  of  the  orbit 
until  it  reaches  the  fissure,  and  is  then  dropped  to  nearly  a  right 
angle  in  its  anterior  posterior  plane  while  the  angle  inward  is 
maintained.  The  point  of  the  needle  should  reach  the  foramen 
rotundum  at  a  depth  of  about  5  cm.  Care  in  directing  the  needle 
is  necessary  in  order  to  avoid  penetrating  the  orbital  contents. 
If  the  direction  of  the  needle  is  not  changed  as  soon  as  the  fis- 
sure is  reached,  the  needle  passes  a  cm.  or  more  below  the  fora- 


Surgical  Operations  with  Local  Anesthesia  in 

men.  On  the  other  hand,  fear  of  injuring  the  orbital  contents 
often  causes  the  operator  to  pass  too  far  laterally  to  the  nerve. 
If  the  needle  enters  the  nerve,  the  patient  feels  pain  in  the  region 
of  distribution  of  the  nerve  and  anesthesia  follows  at  once  when 
the  fluid  is  injected.  If  the  fluid  must  reach  the  nerve  by  diffu- 
sion 10  or  15  minutes  elapse  before  anesthesia  begins,  and  if  the 
needle  is  too  far  laterally  complete  anesthesia  may  not  take  place 
at  all. 

RESECTION    OF   THE   INFRAORBITAL    NERVE. This    nerve    is   to    be 

blocked  at  the  foramen  rotundum.  If  the  needle  actually  pene- 
trates the  nerve  anesthesia  follows  quickly  in  the  entire  area  of 
distribution.  Usually  one  must  wait  15  or  20  minutes  for  anes- 
thesia by  diffusion  to  take  place.  During  this  interval  the  opera- 
tor may  infiltrate  a  line  along  the  lower  border  of  the  orbit  and 
over  the  edge  of  the  floor  of  the  orbit,  and  may  also  inject  the 
nerve  at  its  exit  from  the  foramen.  This  insures  painless  inci- 
sion of  the  skin  and  isolation  of  the  nerve  even  though  infiltra- 
tion of  the  nerve  at  the  foramen  rotundum  be  incomplete  or 
tardy.  The  orbital  soft  parts  should  be  elevated  by  a  retractor, 
and  the  infraorbital  canal  found  by  passing  a  small  probe  (a 
stylet  from  a  needle)  into  the  infraorbital  foramen.  The  canal 
should  be  exposed  by  a  small  chisel,  and  the  nerve  lifted  out, 
and  injected  as  far  back  as  possible,  if  there  is  any  pain.  In 
this  manner  it  is  possible  to  secure  complete  anesthesia,  even  if 
the  attempt  at  blocking  at  the  foramen  rotundum  has  failed.  The 
nerve  should  then  be  fixed  by  a  ligature  and  cut  distally  to  it. 
This  gives  an  anchor  to  the  portion  of  the  nerve  between  the 
point  of  severance  and  the  foramen  rotundum.  A  Jarvis,  or 
similar  nasal  snare,  is  now  threaded  over  the  anchor  string  and 
segment  of  nerve,  and  pushed  back  as  far  as  possible.  The 
nerve  is  cut  off,  or  the  loop  may  be  drawn  taut,  and  the  nerve 
torn  loose  from  the  ganglion.  The  distal  part  of  the  nerve  should 
then  be  pulled  into  the  cheek  through  the  infraorbital  foramen 
and  windlassed  out  of  the  cheek  as  far  as  possible  by  winding 
about  a  nair  of  forceps. 


1 


112 


Surgical  Operations  with  Local  Anesthesia 


OPERATIONS     ON     THE     THIRD     BRANCH. — OfferhaUS      (Dciltsch, 

med.  Wchenschr,  1910,  XXXVI,  1527),  has  devised  an  elabo- 
rate system  of  measurements  designed  to  locate  accurately  the 
foramen  ovale.  Simpler  and  quite  adequate  is  the  method  of 


H  ig.  4(i.     Direction  of  passing  the  needle  from  the  middle  of  the  lower  border  of  the 
zygomatic  arch  toward  the  base  of  the  mastoid  process  of  the  opposite  side. 

Braun  (Dcittsch,  ztsch.  f.  Chir.,  1911,  CXI,  321).  He  passes 
the  needle  directly  inward  for  a  distance  of  4  to  5  cm.  at  the 
lower  border  of  the  middle  of  the  zygomatic  arch.  The  ptery- 
goid  process  should  be  encountered  at  this  depth,  which  should 
be  measured  accurately.  He  then  withdraws  the  needle  until 


Surgical  Operations  with  Local  Anesthesia  113 

the  point  reaches  the  subcutaneous  tissue,  and  then  reintrocluces 
it  to  an  equal  depth,  but  in  a  direction  slightly  farther  back. 
This  describes,  according  to  my  experience,  an  imaginary  line 
passing  2  or  3  cm.  above  the  mastoid  process  of  the  opposite  side 
(Fig.  46).  When  the  needle  reaches  the  depth  at  which  it  had 
previously  touched  the  pterygoid  process  it  should  be  in  contact 
with  the  nerve.  If  pain  or  paraesthetic  sensations  are  not  feh 
by  the  patient  in  the  region  of  the  distribution  of  the  nerve,  the 
needle  may  be  cautiously  passed  a  few  mms.  deeper.  Here  sev- 
eral cc.  of  a  i  or  2  per  cent,  novocain-epinephrin  solution  are 
deposited.  In  order  to  mark  the  required  distance  upon  the 
needle,  Braun  places  a  cork  disc  upon  it.  In  lieu  of  this  a  small 
forceps  or  serrefine,  or  a  Crile  vessel  clamp,  may  be  attached  to 
the  needle  to  mark  the  depth.  Such  apparatus  has  the  advantage 
that  is  more  easily  sterilized  than  the  cork,  and  is  more  likely  to 
be  at  hand  when  needed.  If  the  needle  is  near  the  length  required 
the  eye  of  the  operator  is  sufficiently  accurate  to  mark  the 
distance. 

The  third  branch  is  best  reached  by  an  opening  through  the 
ascending  ramus  of  the  lower  jaw.  A  modification  of  the  clas- 
sical operation  can  be  performed  as  follows :  after  blocking  the 
nerve  in  question  at  its  exit  from  the  foramen  ovale,  or  by  block- 
ing of  the  ganglion  according  to  the  method  already  described, 
the  skin  and  deeper  tissues  are  infiltrated,  from  a  point  begin- 
ning below  the  lower  angle  of  the  malar  bone,  extending  back- 
ward along  the  lower  border  of  the  zygoma  to  the  posterior  bor- 
der of  the  ascending  ramus  and  then  downward  for  5  cm.  The 
triangular  flap  is  then  raised  downward  and  forward,  keeping 
close  to  the  bone.  The  perpendicular  limb  of  the  incision  at  its 
lower  half  should  pass  through  the  skin  only,  dependence  being 
placed  upon  blunt  dissection  for  the  deeper  tissues,  thus  avoiding 
injury  to  the  facial  nerve  and  parotid  gland.  When  the  flap  is 
raised  the  loose  tissue  below  the  ramus  is  infiltrated  by  injecting 
3  to  5  cc.  of  fluid.  This  injection  may  be  made  at  the  time  the 


114  Surgical  Operations  ^v^th  Local  Anesthesia 

roots  of  the  nerves  are  blocked,  or  when  the  skin  infiltration  is 
made  by  passing  the  needle  obliquely  downward  as  much  as  pos- 
sible. Instead  of  trephining  an  opening  through  the  ascending 
ramus  and  enlarging  the  opening  upward,  time  can  be  saved  and 
the  sensibilities  of  the  patient  spared  by  enlarging  the  notch  from 
above  downward  with  a  Dahlgren  forceps. 

The  external  pterygoid  muscle  is  then  located,  and  the  nerve 
will  be  found  at  its  lower  border,  lying  on  the  internal  pterygoid, 
buried  in  loose  tissue,  which  may  be  removed  by  forceps.  The 
nerve  is  grasped  with  forceps,  the  external  pterygoid  retracted 
upward  and  the  nerve  resected  at  its  exit  from  the  foramen 
ovale.  The  lower  portion  of  the  nerve  is  wound  about  a  forceps 
and  the  nerve  divulsed  from  below.  After  the  removal  of  the 
nerve  the  external  and  internal  pterygoid  muscles  may  be  co- 
apted,  where  they  come  in  contact,  with  silk  sutures  in  order  to 
hinder  the  passage  of  the  redeveloping  nerve.  This  in  a  meas- 
ure closes  the  channel  which  the  regenerating  nerve  would  other- 
wise traverse. 

The  nerve  may,  likewise,  be  reached  at  the  point  where  it 
enters  the  mandible.  The  overlying  soft  parts  are  infiltrated 
in  a  line  along  the  lower  border  of  the  angle  of  the  jaw,  begin- 
ning below  the  point  where  the  facial  nerve  crosses  the  maxilla 
and  extending  around  the  angle  of  the  jaw  over  and  parallel  with 
the  horizontal  ramus  for  an  inch.  The  incision  is  made  down  to 
the  bone  and  all  soft  parts  are  raised  from  the  bone  and  sharply 
retracted  upward.  By  means  of  a  burr  or  a  trephine  the  bone 
is  removed  at  a  point  midway  between  the  anterior  and  posterior 
borders  of  the  ascending  ramus  on  a  line  parallel  with  the  free 
border  of  the  teeth  of  the  lower  jaw,  which  exposes  the  canal 
in  which  the  nerve  lies.  By  raising  the  nerve  from  its  bed  it 
can  be  severed  at  its  upper  part  and  the  lower  end  pulled  from 
the  canal  'below.  The  canal  thus  emptied  may  be  filled  with 
some  non-absorbable  material,  preferably  soft  paraffin,  or  the 
disc  removed  by  the  trephine  replaced. 

This  operation  can  be  done  without  first  blocking  the  nerves 


Surgical  Operations  with  Local  Anesthesia  115 

at  the  foramen  ovale,  and  can  be  carried  out  by  those  whose 
experience  with  local  anesthesia  would  not  warrant  them  in 
undertaking  the  more  formidable  operation  described. 

The  lingual  nerve  may  be  reached  at  the  side  of  the  root  of 
the  tongue,  operating  through  the  mouth.  The  nerve  may  be 
blocked  at  the  lingula  or  may  be  blocked  where  it  lies  close  to 
the  bone  at  the  root  of  the  wisdom  teeth,  according  to  the  method 
of  Skillern  (Surg.  Gynec.  and  Obst.,  1913,  XVII,  114).  He  pro- 
jects a  line  from  the  last  molar  tooth  to  the  angle  of  the  mandi- 
ble, the  nerve  crosses  this  line  half  an  inch  below  the  tooth. 


CHAPTER  IX 
OPERATIONS  ON  THE  TONSILS  AND  ADENOIDS 

OPERATIONS  ON  THE  TONSILS. — In  young  children  general 
anesthesia  is  still  required  for  the  removal  of  tonsils.  In  adults 
the  infliction  of  general  anesthesia  is  a  demonstration  that  the 
operator  is  unacquainted  with  the  technic  of  local  anesthesia. 
The  technic  of  tonsil  removal  is  made  vastly  easier,  because 
the  upright  position  enables  the  operator  better  to  observe  the 
relation  of  tonsil  and  pillars,  and  when  novocain-epinephrin  is 
used  the  bloodless  field  further  simplifies  the  operation  enor- 
mously. 

This  is  particularly  true  in  operations  in  the  acute  stage.  Most 
operators,  it  is  true,  refuse  to  remove  tonsils  when  in  a  state  of 
acute  inflammation,  but  my  observation  of  the  results  obtained 
by  the  pioneer  in  this  work,  Dr.  T.  L.  Higginbothon,  of  Hutch  - 
inson,  Kansas,  has  fully  convinced  me  that  the  operation  will 
soon  be  done  as  a  matter  of  routine  in  the  acute  stage  of  inflam- 
mation. The  material  placed  at  my  disposal  for  pathological 
study  makes  it  obvious  to  me  that  the  same  problems  are  repeated 
in  acute  tonsilitis  which  we  have  already  come  to  recognize 
in  the  acute  inflammation  of  appendicitis. 

Two  agents  are  at  our  disposal  for  inducing  local  anesthesia 
for  the  removal  of  tonsils — novocain  and  quinine.  Novocain- 
epinephrin  has  the  advantage,  in  that  it  gives  a  bloodless  field, 
thus  rendering  the  operation  much  more  simple.  It  has  the  dis- 
advantage that  after  the  effect  of  the  epinephrin  wears  off,  oozing 
sometimes  occurs.  In  order  to  secure  the  full  hemostatic  effect 
of  epinephrin  the  injection  should  precede  the  operation  by  at 
least  fifteen  minutes.  At  least  eight  minims  of  epinephrin  should 
be  used  in  one  ounce  of  i  per  cent,  novocain  solution.  The  full 
action  of  the  epinephrin  is  particularly  desirable  when  removing 
tonsils  in  the  acute  stage  of  inflammation. 

116 


Surgical  Operations  with  Local  Anesthesia 


117 


Quinine  and  urea  hydrochloride  controls  the  after-pain  effec- 
tually, but  the  hemorrhage  at  the  time  of  operation  is  greater. 
It  has  the  advantage,  however,  in  that  when  the  hemorrhage  has 
once  ceased,  oozing  does  not  recur.  When  patients  are  to  be 
treated  ambulant  this  drug  is  therefore  to  be  preferred. 

Dr.  W.  R.  Dillingham  combines  these  two  anesthetics.     This 


Fig.  47.     Points  for  injection  preliminary  to  tonsilectomy. 

results  in  the  sacrifice  of  some  of  the  advantages  of  epinephrin 
when  this  is  used  with  novocain  alone ;  hemorrhage  by  this  com- 
bination being  greater  than  when  novocain-epinephrin  is  used 
without  the  quinine.  This  combination  adds  materially  to  the 
after-comfort  of  the  patient,  however. 

Whichever  drug  is  used  the  technic  is  the  same.    The  solution 
is  injected  about  the  capsule  of  the  tonsils  with  or  without  a  pre- 


1 1.8  Surgical  Operations  with  Local  Anesthesia 

liminary  swabbing  of  the  surface  of  the  pillars.  The  needle  is 
passed  through  the  pillar  as  indicated  in  Fig.  47.  The  distance 
from  the  edge  of  the  pillar  at  which  the  needle  is  made  to  enter 
depends  on  the  type  of  tonsil.  In  submerged  tonsils  the  injection 
must  be  made  farther  from  the  edge  of  the  pillar.  At  least  two 
points  of  injection  should  be  made  over  the  body  of  the  tonsil 
and  one  at  the  upper  pole  and  one  at  the  lower  pole.  This  latter 
injection  is  the  most  important  and  is  the  one  most  difficult  to 
make.  Tonsils  frequently  project  deeply  down  beneath  the 
pillars  toward  the  root  of  the  tongue.  The  injection  must  reach 
below  the  tonsillar  tissue.  If  this  is  done  the  pain  complained  of 
when  the  snare  is  tightened  will  not  be  experienced.  The  pos 
terior  pillar  is  injected  in  a  like  manner.  This  may  be  made  diffi- 
cult if  the  tonsil  is  very  large  and  protuberant. 

Both  tonsils  should  be  injected  before  the  operation  is  begun. 
In  this  manner  the  tonsil  first  injected  is  being  acted  upon  by  the 
anesthetic,  while  its  fellow  is  being  injected.  This  reduces  very 
materially  the  time  necessary  to  wait  on  the  anesthetic. 

Instead  of  using  solutions  of  i  per  cent,  strength,  one  of  half 
this  strength  may  be  employed  and  the  tissue  about  the  tonsil 
edematized.  This  makes  the  tonsil  stand  out  more  prominently 
and  in  a  measure  facilitates  removal. 

ADENECTOMY. — It  is  difficult  to  anesthetize  this  region.  Sprays 
into  the  vault  of  the  pharynx,  or  application  on  a  carrier,  may 
be  employed,  but  application  through  the  nares  is  most  usually 
done.  Carriers  armed  with  cotton  are  carried  through  the  nose 
to  the  vault  of  the  pharynx,  and  are  frequently  renewed  until 
anesthesia  is  obtained. 

This  operation  is  most  often  needed  in  childhood,  when  any 
type  of  anesthesia  is  difficult.  The  operation  requires  but  a 
moment  and  is  not  painful  and  is  well  borne.  General  anesthe- 
sia may  be  employed,  but  is  vastly  more  dangerous  than  the 
operation  itself,  because  of  the  possibility  of  blood  aspiration — 
an, accident  not  certainly  obviated  even  by  operating  in  the  hang- 
ing head.  I  prefer  always  to  operate  with  local  anesthesia  or 
with  no  anesthesia  at  all. 


CHAPTER  X 
OPERATIONS  ON  THE  THYROID  AND  LARYNX 

The  structures  in  the  anterior  region  of  the  neck  requiring 
surgical  treatment  are  relatively  superficial  and  have  a  well 
denned  nerve  supply.  For  these  reasons  they  are  particularly 
well  adapted  to  operation  under  local  anesthesia,  and  fortunately 
so,  for  operations  upon  both  the  thyroid  gland  and  the  trachea  are 
usually  required  under  conditions  in  which  general  anesthesia 
is  inconvenient  or  hazardous.  Tracheotomy  is  often  required 
when  the  operator  is  working  alone,  and  the  patient  finds  his 
supply  of  oxygen  limited  enough  by  his  disease  without  having 
it  diluted  with  a  general  anesthetic.  The  operation,  too,  is  much 
simplified  by  the  use  of  the  local  anesthetic,  because  not  only  is 
the  congestion  reduced  by  the  epinephrin,  but  the  additional 
hyperemia  from  the  inhalation  of  a  general  anesthetic  is  absent. 
It  is  to  the  removal  of  the  thyroid  gland,  however,  that  local 
anesthesia  is  most  frequently  applied.  Danger  from  pulmonary 
and  cardiac  collapse  are  eliminated,  and  compression  of  the 
trachea  is  easily  prevented  or  managed.  Here  even  more  than  in 
tracheotomy  the  relatively  bloodless  field  is  to  be  appreciated, 
because  it  facilitates  the  avoidance  of  the  parathyroid  glands  and 
the  recurrent  laryngeal  nerve.  The  operator  is  much  less  likely 
to  hurry  the  operation  when  working  under  local  anesthesia  than 
when  he  is  apprehensive  of  the  general  anesthetic  and  is  able 
to  work  more  carefully.  In  hyperthyroidism  all  these  advan- 
tages are  of  maximum  value.  Hyperthyroid  patients  may  require 
some  primary  treatment  on  account  of  their  nervous  state,  but 
in  this,  as  in  most  other  operations  done  under  local  anesthesia, 
they  are  apt  to  show  as  much  poise  and  confidence  as  the  opera- 
tor does.  With  proper  technic  thyroidectomy  becomes  an  ideal 
operation  for  local  anesthesia. 

NEURAL  ANATOMY. — The  nerves  to  be  anesthetized  in  opera- 

119 


I2O  Surgical  Operations  with  Local  Anesthesia 

tions  upon  the  anterior  portion  of  the  neck  are  confined  largely 
to  the  superficial  structures.  The  chief  are  the  cutaneous  colli, 
which  spring  from  the  second  and  third  branches  of  the  cervical 
plexus,  pass  beneath  the  sterno-mastoid  muscle,  and  curve 
over  its  posterior  border  (Fig.  48),  and  then  extend  forward 
under  the  platysma,  supplying  the  skin  of  the  anterior  surface 


Fijc.  48.     Superficial  nerves  of  the  anterior  region  of  the  neck. 


of  the  neck  from  the  chin  to  the  sternum.  The  auricularis  mag- 
nus  springs  likewise  from  the  second  and  third  branches  of  the 
cervical  plexus,  passes  around  the  posterior  border  of  the  sterno- 
mastoid  and  supplies  the  skin  in  the  region  of  the  angle  of  the  jaw. 
These  nerves  also  send  twigs  to  the  muscles  in  this  region.  The 
muscles  in  addition  receive  twigs  from  the  Spinal  accessory  and 
the  Glossopharyngeal.  These  latter  nerves  supply  the  fascia. 
The  two  principal  nerves  curve  around  the  posterior  border  of 
the  sterno-mastoid  muscle  near  together  at  the  level  of  the  thy- 
roid cartilage  and  can  be  blocked  with  ease  and  certainty. 


Surgical  Operations  with  Local  Anesthesia  121 

The  deep  nerves  of  the  neck  are  of  importance  because  they 
must  be  shielded  from  injury.  They  are  the  inferior  or  recurrent 
laryngeal,  the  superior  laryngeal  and  the  hypoglossal.  The  two 
recurrent  laryngeal  nerves  after  springing  from  the  vagus  on  the 
right  side,  in  front  of  the  subclavian  artery,  and  on  the  left,  in 
front  of  the  aortic  arch,  wind  beneath  these  vessels  from  before 
backward,  and  are  then  directed  upward  and  inward  to  the 
groove  betweeen  the  trachea  and  esophagus.  They  reach  the 
larynx  by  passing  under  the  lower  border  of  the  inferior  con- 
strictor of  the  pharynx.  In  their  passage  upward  they  come  in 
contact  with  the  inferior  thyroid  artery,  passing  sometimes  over 
it  and  sometimes  between  its  branches  when  this  vessel  undergoes 
early  division.  The  superior  laryngeal  nerve  springs  from  the 
ganglion  of  the  trunk  of  the  vagus,  passes  downward  and  inward 
and  reaches  the  larynx  by  passing  behind  the  carotid  vessels. 
Its  high  position  keeps  it  out  of  harm's  way,  except  where  the 
thyroid  is  very  large,  and  the  thyroid  vessels  are  displaced  up- 
wards, when  it  may  be  exposed  in  searching  for  the  vessels. 
The  hypoglossal  is  of  importance  only  because  of  its  descending 
branch.  This  nerve  may  be  encountered  in  the  depth  of  the 
wound  and  may  give  the  operator  fright  lest  he  has  severed  the 
inferior  laryngeal  nerve.  The  interior  of  the  trachea  is  supplied 
by  twigs  from  the  vagus  mostly  through  the  recurrent  laryngeal 
and  the  sympathetic. 

TRACHEOTOMY. — Local  infiltration  is  sufficient  to  produce 
anesthesia  in  this  operation.  The  line  of  the  proposed  incision 
is  first  infiltrated,  then  the  subcutaneous  tissues,  and  from  the 
same  line  the  tissues  about  the  trachea  are  injected  by  directing 
the  needle  laterally  and  posteriorly  (Fig.  49).  By  slipping  the 
skin  laterally  it  is  possible  to  infiltrate  the  space  between  the 
trachea  and  esophagus,  thus  reaching  the  nerves  supplying  the 
mucous  membrane.  The  effect  that  might  be  produced  by  anes- 
thetizing both  recurrent  nerves  is  not  known.  One  nerve  may  be 
blocked  without  unpleasant  effects,  and  it  is  a  matter  of  experi- 
ence that  the  vagus  of  one  side  may  be  resected  in  malignant 


122  Surgical  Operations  with  Local  Anesthesia 

disease  with  impunity.  If  intratracheal  manipulations  are  re- 
quired it  is  probably  safer  to  use  topical  application  to  the  mucous 
membrane,  though  probably  no  undesirable  results  need  be  feared 
if  all  the  nerves  supplying  the  larynx  are  simultaneously  blocked. 
At  any  rate  if  trachectomy  is  the  operation  at  hand  the  relief 
for  closure  of  the  glottis  is  readily  applied. 


Fig.  49.     Infiltration  lines  for  tracheotomy  and  laryngotomy. 


When  the  infiltration  has  been  completed  the  operation  is 
carried  out  in  the  usual  manner.  The  question  of  hemorrhage 
is  much  simplified  by  the  use  of  epinephrin.  Careful  hemostasis 
must  not  be  neglected  lest  bleeding  occur  after  the  effect  of  the 
epinephrin  wears  off. 

When  the  low  operation  is  to  be  done  it  is  well  to  infiltrate 
the  isthmus  of  the  thyroid  down  to  the  trachea  so  that  the  sepa- 
ration of  these  two  structures  will  not  be  painful.  If  necessary 
the  isthmus  may  be  partly  or  completely  severed  in  order  to  ob- 


Surgical  Operations  with  Local  Anesthesia  123 

tain  room  for  the  tube.  This  latter  may  be  desirable,  particu- 
larly in  extensive  involvement  of  the  larynx  by  malignant  dis- 
ease. 

LARYNGOTOMY. — Infiltration  of  the  soft  parts  for  this  opera- 
tion does  not  differ  materially  from  that  for  tracheotomy.  By 
passing  the  needle  along  the  upper  border  of  the  cartilage  the 
mucous  membrane  can  be  effectually  anesthetized.  All  the  tis- 
sue about  the  larynx  can  be  readily  infiltrated  with  a  straight 
needle  by  sliding  the  line  of  skin  infiltrated  first  to  one  side,  then 
to  the  other.  The  mucous  membrane  will  need  to  be  anesthetized 
either  by  topical  application  or  by  injection  with  a  small  needle. 
This  is  particularly  necessary  when  the  removal  of  tumors  is  the 
object  of  the  operation. 

EXTIRPATION  OF  THE  LARYNX. — This  operation  is  nearly  always 
done  for  carcinoma  before  obstructive  symptoms  develop  and 
may  be  performed  in  one  or  two  stages.  The  plan  of  Berard 
and  Surgnon  may  be  adopted.  In  the  first  stage  they  did  i 
tracheotomy,  and  delayed  the  extirpation  for  a  week  or  ten  days 
until  the  patient  had  become  accustomed  to  the  new  way  of 
breathing.  Removal  of  the  cervical  lymph  glands,  if  necessary, 
should  be  done  in  the  first  stage,  in  order  that  the  wound  may 
heal  before  it  is  exposed  to  the  pharyngeal  secretions. 

In  addition  to  the  blocking,  as  done  for  laryngotomy,  it  is 
necessary  in  extirpation  of  the  larynx  to  infiltrate  the  constric- 
tors of  the  pharynx  and  the  tissue  between  the  larynx  and 
pharynx.  The  needle  should  be  introduced  at  a  point  lateral  to 
the  pharynx  in  order  that  all  the  tissues  may  be  reached.  For 
deep  infiltration  ^4  Per  cent,  novocain  is  sufficient.  If  a  trans- 
verse incision  is  to  be  made  the  lateral  injection  may  be  made 
from  the  extremity  of  the  line  of  the  skin  infiltration.' 

THYROIDECTOMY. — The  curved  incision  of  Kocher  is  now  used 
by  most  surgeons.  It  is  of  particular  advantage  in  operating 
under  local  anesthesia,  because  it  gives  free  access  to  the  gland 
without  tugging. 

The  skin  line  is  infiltrated  first.     For  goiters  of  medium  size 


124 


Surgical  Operations  ivith  Local  Anesthesia 


the  line  begins  over  the  sterno-mastoid  of  the  side  opposite  the 
lobe  to  be  removed,  extends  horizontally  across  the  neck  over  the 
center  of  the  isthmus  of  the  thyroid,  curving  slightly  upward  to 
reach  the  outer  border  of  the  opposite  sterno-mastoid  at  the 
level  of  the  thyroid  cartilage  (Fig.  50).  It  is  then  continued  up- 
ward toward  the  angle  of  the  jaw  (Fig.  51)  or  as  far  as  required 
for  the  particular  goiter.  The  fascia  and  platysma  are  then  infil- 


Fig.  50.     Skin  infiltration  for  removal  of  thyroid. 

trated  through  this  line.  In  very  large  goiters  the  muscles  of 
the  region  have  usually  been  pushed  to  one  side  so  that  they 
require  no  special  attention.  In  moderate  sized  and  smaller 
glands  the  muscle  layers  should  be  infiltrated. 

The  chief  nerves  of  the  region  are  now  blocked  where  they 
lie  beneath  the  sterno-mastoid  muscle.  The  line  of  infiltrated 
skin  is  pulled  laterally  until  the  needle  can  be  passed  through  it 
behind  the  muscle,  and  the  anesthetic  solution  is  deposited  at  thi,c 


Surgical  Operations  with  Local  Anesthesia 


125 


point.  The  cervical  nerves  pass  around  the  sterno-mastoid  mus- 
cle at  this  point  (Fig.  48)  and  are  readily  blocked  with  certainty. 
The  tissues  behind  the  gland  are  now  infiltrated  by  introducing 
a  long  needle  through  the  same  point,  behind  the  cartoid  sheath 
(Fig.  52),  and  as  far  as  the  esophagus,  if  possible.  In  large 
goiters  the  sterno-mastoid  muscle  and  the  carotid  sheath  are 
displaced  far  outward  and  backward.  In  that  advent  it  is  neces- 
sary to  pass  the  needle  anterior  to  the  muscle  and  carotid  sheath, 
but  behind  the  parotid.  With  care  this  can  be  readily  accom- 


Fig.  51.     Lateral  view  of  skin  infiltration. 


plished,  even  when  the  gland  presents  many  irregularities  and 
bossilations.  Many  goiters  present  very  long  extensions,  up- 
ward. In  one  of  my  patients  the  tip  of  the  lobe  was  plainly 
visible  in  the  mouth  beside  the  epiglottis.  In  such  cases  the 
infiltration  behind  the  gland  must  be  carried  as  high  as  possible. 
If  the  infiltration  is  carried  as  high  as  the  superior  thyroid  ves- 
sels, any  portion  extending  above  this  point  can  be  shelled  out 
without  pain  without  further  infiltration. 


126 


Surgical  Operations  with  Local  Anesthesia 


Failure  to  secure  reliable  anesthesia  is  usually  due  to  a  too 
timid  infiltration  of  the  deeper  tissues  of  the  neck.  The  carotid 
artery  and  the  structures  accompanying  it  can  easily  be  avoided 
by  noting  the  pulsations  of  the  vessel. 

The  tissue  about  the  isthmus  is  then  infiltrated  by  dislocating 
the  line  of  skin  infiltration  first  upward  and  then  downward. 
The  isthmus  is  next  directly  injected. 


Fig.  o'2.     Infiltration  of  the  tissues  posterior  to  the  sterno-mastoid  muscle  and  the 
tissues  behind  the  gland.     The  needle  passes  beyond  the  carotid  sheath. 


By  the  time  these  infiltrations  are  completed  the  original  skin 
infiltration  has  produced  an  effective  anesthesia,  and  the  blood 
vessels  have  become  contracted  from  the  action  of  the  epine- 
phrin.  This  is  an  advantage  which  emphasizes  the  value  of 
making  the  skin  infiltration  first  instead  of  afterward,  as  the 
German  school  has  advocated.  With  the  vascular  constriction 
the  small  vessels  are  invisible,  and  the  larger  veins  stand  out  in 


Surgical  Operations  with  Local  Anesthesia 


127 


bold  relief,  and  are  to  be  carefully  separated  from  the  surround- 
ing tissue,  doubly  ligated  and  cut.  The  platysma  is  men  severed 
and  if  any  bleeding  points  appear  they  are  caught  up  and  ligated 
at  once  before  the  incision  is  extended.  The  muscles  in  front 
of  the  thyroid  are  then  severed,  unless  they  have  been  pushed  out 
of  the  way  by  the  enlargement  of  the  gland.  If  any  bleeding 
points  appear,  and  usually  there  are  none,  they  are  ligated  at 


Fig.  .>'{.     Secondary  blocking  about  the  superior  pole  of  the  thyroid. 

once.     If  the  incision  is   found  too  short  to  expose  the  gland 
without  undue  traction  it  is  to  be  enlarged. 

The  capsule  of  the  thryoid  is  now  carefully  exposed,  taking 
care  to  sever  each  fascial  layer  covering  the  gland.  Often  there 
are  more  layers  than  one  expects.  Care  should  be  taken  not  to 
injure  the  vessels  in  the  true  capsule  lest  troublesome  hemorrhage 


128 


Surgical  Operations  with  Local  Anesthesia 


ensue.  Too  much  attention  cannot  be  paid  to  keeping  the  wound 
free  from  blood  so  that  every  structure  may  be  recognized  before 
it  is  handled.  The  success  of  the  operation  may  depend  upon 
this. 

The  ringer  is  now  slowly  and  gently  introduced  between  the 
lateral  border  of  the  tumor  and  the  sterno-mastoid  muscle.     If 


Fig.  54.     Ligation  of  superior  thyroid  vessels. 

the  patient  feels  pain  the  operator  must  admit  that  he  is  still  a 
novice  to  the  art  of  local  anesthesia,  and  must  resort  to  infiltra- 
tion immediately  about  the  tumor  (Fig.  53).  By  gradually  insin- 
uating the  finger  between  the  tumor  and  the  surrounding  tissue, 
the  gland  is  dislocated  and  the  superior  thyroid  vessels  located. 


Surgical  Operations  with  Local  Anesthesia 


129 


They  are  separated  from  the  surrounding  tissue,  doubly 
ligated  (Fig.  54)  and  severed.  Less  traction  is  produced  by  this 
means  than  by  clamping,  cutting  and  then  ligating  as  most  opera- 
tors do  when  operating  under  general  anesthesia.  Often  acces- 


Fig. 


Ligation  of  inferior  thyroid  vessels. 


sory  lobulations  confuse  the  operator  either  before  or  after  the 
vessels  are  located.  The  upper  part  of  the  tumor  is  now  sepa- 
rated from  the  surrounding  tissue. 

The  tumor  is  now  isolated  toward  the  lower  pole,  a  procedure 
which  is  much  easier  because  of  the  vessel-constricting  action 
of  the  epinephrin.  By  care  the  para-thyroid  glands  may  be 
avoided,  even  if  they  are  imbedded  in  depressions  within  the 


13°  Surgical  Operations  -with  Local  Anesthesia 

gland.  As  the  gland  is  elevated  the  inferior  vessels  come  into 
view  (Fig.  55).  If  the  separation  of  the  lower  pole  is  painful, 
infiltration  may  be  made  about  the  gland  before  proceeding.  The 
vessels  must  be  isolated  before  being  tied  so  that  the  recurrent 
nerve  is  not  caught  in  the  ligature.  This  accident  is  less  likely 
to  happen  with  the  use  of  a  double  ligature  than  with  clamps. 
Sometimes  when  the  lower  pole  extends  far  down  behind  the 
sternum  and  clavicle,  one  may  have  difficulty  in  reaching  the 
vessels.  Having  the  patient  cough,  as  recommended  by  some 
German  writers,  in  order  to  force  the  gland  upward,  I  have  found 
astonishingly  effective.  When  the  goiter  is  thus  propelled  out  of 
its  deep  seat,  the  vessels  are  easily  secured  and  ligated. 

It  now  remains  only  to  remove  the  gland  from  the  trachea. 
In  order  to  minimize  the  almost  unavoidable  choking  sensation, 
the  gland  should  be  separated  by  using  some  blunt  instrument 
rather  than  by  forcible  rotation  of  the  tumor.  The  gland  then 
remains  attached  only  by  the  isthmus,  which  if  large  is  crushed 
with  forceps  and  ligated,  and  if  small  may  be  ligated  without 
crushing. 

If  the  technic  has  been  carefully  carried  out  the  removal  of 
the  gland  leaves  a  dry  bed  and  a  wound  unincumbered  with 
forceps.  To  close  the  wound,  the  muscles  are  sutured  into  place 
and  the  superficial  structures  united  in  any  manner  that  may  suit 
the  operator. 

In  ordinary  goiters  no  preliminary  preparation  is  necessary, 
except  a  hypodermic  of  1-6  gr.  of  morphine.  The  skin  is  painted 
with  iodine  after  the  patient  is  on  the  table.  Novocain-epinephrin 
is  the  anesthetic  of  choice.  For  blocking  of  the  nerves  a  I  per 
cent,  solution  is  preferable,  while  for  the  deeper  infiltrations  y2 
per  cent,  or  less  is  adequate.  In  very  large  goiters,  I  use  quinine 
and  urea  hydrochloride  in  the  skin  and  fascia,  reserving  the  novo- 
cain  for  the  deeper  structures.  Quinine,  when  used  in  the  muscles 
and  loose  tissues  of  the  neck,  produces  a  thin  reddish  exudate, 
which  interferes  with  healing  and  may  produce  an  annoying 
woody  induration  of  the  surrounding  tissues  which  may  last  for 


Surgical  Operations  i^'itJi  Local  Anesthesia  131 

weeks.  It  sometimes  produces  slight  disturbances  in  healing 
of  the  skin  wound.  By  employing  both  drugs,  I  have  never 
been  obliged  to  use  more  than  two  grains  of  quinine  and  urea 
and  five  grains  of  novocain  with  eight  drops  of  epinephrin. 

Patients  suffering  from  hyperthyroidism  are  more  difficult  to 
operate  upon  than  those  who  have  simple  goiters.  This  is  due 
in  part  to  the  fact  that  the  glands,  being  usually  small,  are  dis- 
located with  difficulty,  but  chiefly  to  the  nervous  state  of  the 
patient.  The  former  difficulty  is  met  by  infiltrating  more  care- 
fully about  the  gland.  In  order  to  minimize  the  latter  disadvan- 
tage, the  patient  must  be  properly  prepared.  Very  nervous 
patients  are  placed  in  bed  and  proper  rest  secured  by  some  means, 
moderate  doses  of  bromides  usually  producing  the  desired  result 
after  a  time.  When  the  patient  has  become  composed,  the  ques- 
tion of  the  relative  pleasantness  of  local  and  general  anesthesia 
is  discussed  with  her.  Danger  is  not  mentioned.  After  the 
patient  has  been  convinced  that  local  anesthesia  will  save  her 
her  from  nausea,  the  time  of  the  operation  is  fixed.  If  she  is  not 
sleeping  well  she  receives  ten  grains  of  veronal  the  evening  be- 
fore the  day  selected  for  the  operation.  On  the  morning  of  the 
operation  she  receives  morphine,  1-6  with  atropin  1-150.  If  the 
patient  has  a  friend  who  has  been  operated  upon  under  local 
anesthesia,  there  is  no  need  for  parley,  for  she  conies  convinced 
of  the  advantages  of  the  method. 

No  primary  scrubbing  or  dressing  is  used.  The  patient  is 
placed  on  the  table  in  a  comfortable  position  with  the  head  tilted 
back,  if  she  finds  this  comfortable ;  if  not,  the  operator  accepts 
the  more  difficult  position.  The  trunk  is  slightly  elevated.  The 
operator  sits  comfortably  beside  his  patient,  neither  being  handi- 
capped in  conversation  by  mask  or  face  covering. 

The  operation  should  be  simply  arranged.  Noise  should  not 
be  permitted.  The  fewer  assistants  the  better,  a  single  assistant 
for  the  surgeon  and  a  nurse  to  run  errands  being  all  that  are 
required.  The  easiest  place  to  operate  is  in  the  patient's  kitchen, 
with  the  bread  pan  as  a  sterilizer  and  the  kitchen  cabinet  as  an 


132  Surgical  Operations  with  Local  Anesthesia 

instrument  table.  Six  artery  forceps,  a  knife,  a  pair  of  scissors. 
two  needles  and  a  perfect  syringe  with  needles,  are  all  the  equip- 
ment the  surgeon  needs.  If  he  has  no  more  apparatus  than  this, 
there  is  less  tendency  to  allow  instruments  to  hang  about  the 
wound,  tugging  upon  it  and  annoying  the  patient.  The  knowl- 
edge that  he  has  but  a  limited  number  of  forceps,  compels  the 
operator  to  acquire  the  habit  of  starting  but  few  points  of  hemor- 
rhage at  a  time  and  ligating  as  soon  as  the  vessels  are  caught  up. 
Retractors  are  not  needed  and  are  objectionable,  because  of  the 
inevitable  traction  thev  cause  on  tissues  outside  of  the  field  of 
operation.  This  method  of  operating  may  require  a  little  more 
time,  but  it  prevents  the  loss  of  blood.  Blood  which  trickles  over 
the  side  of  her  neck  and  shoulder  and  finallv  beats  a  tattoo  in 
the  sponee  pan,  is  very  apt  to  elicit  interrogatory  remarks  from 
exophthalmic  patients. 

The  secret  of  success  in  thvroidectomv  under  local  anesthesia 
is  that  the  sure-eon  must  not  hurt  the  patient.  The  field  must  be 
completely  anesthetized,  and  must  be  kept  free  from  b1ond 
The  latter  is  impossible  unless  the  former  is  realized,  because  if 
the  patient  suffers  pain  the  necessary  delicacv  in  terhnic  renuired 
to  perform  a  bloodless  operation  is  not  possib1e.  With  all  details 
mastered  thvroidectomy  under  local  anesthesia  becomes  an  ex- 
ceedingly satisfactory  and  simple  operation. 


CHAPTER  XI 
OPERATIONS  ON  THE  MAMMARY  GLAND 

Because  of  the  great  extent  of  the  wound  required  in  the  radi- 
cal removal  of  the  breast  and  its  diversified  nerve  supply,  this 
operation  does  not  lend  itself  readily  to  performance  under  local 
anesthesia.  Nevertheless,  the  radical  operation  may  be  satisfac- 
torily done  if  there  are  contraindications  to  general  anesthesia. 
In  thin  women  this  is  readily  accomplished,  but  in  fat,  muscular 
patients  the  tax  on  the  operator's  time  and  resources  is  consid- 
erable. It  is  just  these  women  that  a  particularly  radical  opera- 
tion is  required,  for  the  vigorous  woman  in  midlife  gives  a  much 
poorer  prognosis  than  the  feeble  aged  woman.  Nevertheless,  I 
find  myself  urged  by  patients  more  and  more  frequently  to  under- 
take the  operation  under  local  even  in  the  more  difficult  cases. 

The  simpler  operations,  such'as  the  removal  of  fibro-adenomas 
and  the  removal  of  the  entire  breast  for  interstitial  mastitis  and 
the  like,  may  well  be  done  under  local  anesthesia  as  a  matter  of 
routine. 

NERVE  SUPPLY. — The  skin  in  the  region  of  the  mammary 
gland  receives  branches  from  the  cervical  plexus  through  the 
sterno-clavicular  and  acromial  nerves,  and  some  twigs  from  the 
intercostal  nerves.  The  breast  itself  is  supplied  by  branches  from 
the  fourth,  fifth  and  sixth  intercostal  nerves.  None  of  these 
nerves  admits  of  blocking  at  its  source.  Therefore,  infiltration 
about  the  field  of  operation  must  be  depended  upon. 

OPENING  OF  ABSCESSES. — Chronic  abscesses  of  the  breast  may 
be  opened  by  simple  infiltration  of  the. skin  in  the  affected  area. 
Acute  abscesses  are  so  wide  in  extent  and  the  parts  so  sensitive 
that  no  form  of  local  anesthesia  is  satisfactory.  Here  gas  or 
ether  "rauch"  finds  an  ideal  application. 

BENIGN  TUMORS. — The  entire  adeno-fibromatous  and  mixed 
tumor  group  is  readily  managed  under  local  anesthesia.  When 

133 


134 


Surgical  Operations  with  Local  Anesthesia 


the  tumor  is  small  a  simple  line  of  infiltration  over  the  summit 
with  infiltration  beneath  makes  its  removal  a  simple  matter. 
With  large  tumors  one  makes  a  circular  infiltration  about  the 
base  and  then  by  means  of  a  long  needle  infiltrates  the  tissue 


Fig.  56.     Infiltration  about  a  benign  breast  tumor  with  infiltration  between  the'iumor  and  the 
surrounding  breast  tissue  (modified  from  Braun). 

between  the  tumor  and  chest  wall  (Fig.  56).  In  this  manner  the 
tumor  may  be  removed  with  more  or  less  of  the  breast  tissue. 
The  operation  may  be  performed  on  ambulatory  patients,  no 
matter  how  large  the  tumor. 

DIAGNOSTIC  INCISION  IN  SENILE  PARENCHYMATOUS  HYPERTRO- 
PHY.— The  most  difficult  problem  in  breast  tumor  surgery  is  the 
differentiation  between  the  malignant  and  benign  states  of  the 
breast  in  women  at  or  near  the  menopause,  when  the  breast  is 
more  or  less  hypertrophied.  For  this  it  is  advisable  to  infiltrate 
the  entire  breast  area  so  that  if  desired  a  part  or  all  of  the  breast 
mav  be  removed. 


Surgical  Operations  with  Local  Anesthesia  13" 

">  '..     ', 

An  ellipse  may  be  infiltrated  about  the  nipple,  or  a  simple 
curved  line  about  the  lower  border  of  the  breast  (Fig.  57).  When 
the  lesion  is  localized,  and  the  question  is  one  of  local  hypertro- 


FIR.  57.     Line  of  infiltration  for  diagnostic  incision  of  the  breast.     This  line  may  be  made 
in  the  fold  so  that  the  resulting  scar  will  be  hidden  by  the  overhanging  breast. 

phy  with  or  without  cyst  formations,  the  elliptical  infiltration  in 
the  skin  may  be  followed  by  an  elliptical  infiltration  of  the  mam- 
mary gland  itself.  The  gland,  particularly  when  the  interstitial 
tissue  is  increased,  is  a  difficult  tissue  to  infiltrate.  It  is  dense 


136 


Surgical  Operations  with  Local  Anesthesia 


and  elastic, .  resists  the  passage  of  the  needle  and  offers ,  great 
resistance  to  the  expulsion  of  the  fluid.  Syringes  with  narrow 
barrels  will  be  convenient  here.  The  "feel"  of  the  tissue  to  the 
needle  alone  is  sufficient  to  differentiate  between  malignant  and 


Fig.  08.      By  sliding  the  skin  over  the  breast  the  area  may  be  infiltrated  without 
puncturing  unanesthetized  skin. 

non-malignant  foci  in  many  instances.  When  the  area  of  involve- 
ment is  more  diffuse  a  single  long  semilunar  line  of  infiltration 
along  the  lower  border  of  the  breast  is  more  convenient  (Fig. 


Surgical  Operations  with  Local  Anesthesia  137 

57).  From  this  line  the  tissue  between  the  breast  and  skin  and 
between  the  breast  and  thoracic  wall  must  be  infiltrated.  This 
is  readily  done  by  sliding  the  breast  about  beneath  the  skin  (Fig. 
58).  The  incision  is  then  made  through  the  skin  down  to  the 
gland  and  the  inferior  edge  of  the  gland  exposed.  The  gland  is 
then  loosened  from  the  thoracic  wall.  The  gland  may  now  be 
cut  into  and  a  search  made  for  malignant  areas.  If  the  operator 
does  not  have  confidence  in  his  clinical  diagnosis,  he  may  excise 
a  suspected  area  and  pass  the  responsibility  up  to  an  interne  or  to 
a  pathologist,  if  one  be  available.  With  the  breast  so  exposed, 
however,  the  "feel"  of  the  breast  to  the  finger  and  to  the  knife 
will  leave  few  cases  in  which  there  is  any  doubt.  'If  not  malig- 
nant a  part  or  all  of  the  gland  may  be  excised  and  the  operation 
terminated. 

If  a  malignant  focus  is  discovered  ether  had  best  be  given  and 
the  operation  terminated  in  the  usual  manner.  It  is  my  practice 
in  cases  in  which  there  is  a  suspicion  of  malignancy  to  state  to 
the  patient  that  there  is  probably  no  malignancy,  but  that  an 
exploratory  incision  under  local  anesthesia  will  settle  the  matter. 
The  patient  is  told  that  if  no  malignant  area  is  discovered,  she 
can  go  home  at  once  if  she  desires,  but  should  malignancy  be 
encountered  ether  will  be  given  and  the  operation  performed  in 
a  radical  manner.  With  such  an  understanding  many  women 
consent  to  a  definite  solution  of  their  problem  who  would  hesitate 
to  accept  without  parley  a  more  radical  procedure. 

The  objection  raised  against  breast  explorations  under  local 
anesthesia  is  that  if  the  operation  turns  out  to  be  more  extensive 
than  was  at  first  expected,  an  incomplete  operation  results.  The 
indictment  is  against  the  operator.  It  implies  that  he  is  unable 
to  foresee  the  possible  extent  of  the  operation  or  that,  seeing 
the  requirements,  has  not  the  courage  to  fulfill  them.  If  he  will 
in  every  instance  bear  in  mind  the  possibility  that  a  radical  opera- 
tion may  be  required  and  be  fully  prepared  to  meet  it  no  expen- 
diture of  courage  will  be  required  to  meet  the  indications. 

THE  RADICAL  BREAST  AMPUTATION. — As  already  stated  this  oper- 


138  Surgical  Operations  with  Local  Anesthesia 

ation  may  be  performed  under  local  anesthesia  on  any  kind  of  a 
patient.  Because  of  the  labor  entailed,  I  volunteer  it  only  in 
women  with  pulmonary  or  cardiac  diseases  and  in  slight,  elderly 
persons. 


•":    •'"  ~y"~f -•'...          --<-":c">,'   *•  •*:  '•; 

X^-^.C?CM/^'V*  >">"' 


ffi 


N^P^     ; 


^AV*^ 


?* 


Fig.  K).     Lines  of  infiltration  for  radical  operation  upon  the  breast.     The  ring  line  indi- 
cates the  skin  infiltration  and  the  arrow  lines  indicate  the  direction  of  the 
deep  infiltration.     These  lines  reach  the  pectoral  fascia. 

The  infiltration  is  begun  by  making  an  ellipse  about  the  nipple, 
circumscribing  the  extent  of  skin  it  is  deemed  necessary  to  sacri- 


Surgical  Operations  ivith  Local  Anesthesia  139 

lice.  This  ellipse  is  extended  along  the  lower  border  of  the 
Pectoralis  major  muscle  to  the  axilla,  thence  down  the  bicipital 
grove  and  upward  just  below  the  clavicle  (Fig.  59).  This 
infiltration  in  the  region  of  the  clavicle  is  made  extensively,  for 
it  not  only  anesthetizes  the  skin,  but  blocks  the  sterno-clavicular 
and  acromial  nerves. 

From  these  primary  lines  the  deeper  tissues  are  infiltrated  both 
about  and  beneath  the  gland,  about  the  brachial  vessels  and  into 
the  tendons  of  the  pectoral  muscles,  and  by  passing  the  needle 
through  these  tendons,  the  loose  tissue  beneath  them  is  reached. 

In  operations  of  this  extent  the  operator  must  ,well  calculate 
the  extent  of  his  resources.  It  is  in  such  operations  that  a 
friendly  relation  with  quinine  is  particularly  important.  This 
anesthetic  may  be  used  in  sufficient  amount  in  the  extensive  skin 
infiltration.  The  thick  skin  of  the  chest  bears  this  anesthetic 
well.  I  do  not  recall  having  noted  delayed  union  after  quinine 
in  this  region.  If  the  axillary  infiltration  requires  a  large  amount 
of  fluid,  I  use  quinine  about  and  beneath  the  mamma  as  well.  In 
small  spare  women  novocain-epinephrin  may  be  used  for  this 
part  of  the  infiltration.  In  large,  powerful  patients  the  novocain 
should  be  saved  for  infiltration  of  the  axilla.  This  drug  is 
very  much  preferable  in  the  loose  axillary  tissue  because  of  the 
bloodless  field  it  procures.  By  palpation  the  axillary  artery  can 
be  located,  and  from  this  by  calculation  the  veins  can  be  avoided. 
The  regions  requiring  particular  care  in  infiltration  is  the  sub- 
scapular  and  infraclavicular  regions.  Because  of  the  looseness 
of  the  tissue  a  }4  Per  cent,  solution  is  sufficient. 

Even  with  abundant  infiltration  of  the  axilla  the  operator 
must  be  on  the  look-out  for  the  long  thoracic,  the  intercosto- 
humeral  and  the  axillary  nerves,  for  the  weak  solution  above 
recommended  will  not  anesthetize  these  relatively  large  nerves. 
They  should,  therefore,  be  blocked  by  infiltration  directly  within 
their  sheaths.  They  may  then  be  avoided  or  resected  as  the 
operator's  temper  prompts  him. 

The  operator  need  not  deviate  from  the  type  of  operation  he 


140  Surgical  Operations  with  Local  Anesthesia 

is  accustomed  to  perform.  I  prefer  to  allow  the  pectoral  muscles 
to  remain.  The  tendons  may  be  severed,  to  facilitate  dissection, 
and  subsequently  reunited.  The  removal  of  a  wide  area  of  skin, 
it  seems  to  me,  is  the  most  vital  factor  in  this '  operation  and 
the  removal  of  any  extent  is  easily  accomplished.  In  fact,  the 
removal  of  skin  coextensive  with  the  breast  area  facilitates  the 
infiltration  of  the  retroglandular  tissues  and  therefore  encour- 
ages a  radical  procedure  in  this  part  of  the  operation. 

In  cases  where  the  breast  tumor  has  been  removed  by  paste, 
or  otherwise  without  attention  to  the  axillary  glands,  the  latter 
can  be  satisfactorily  removed  under  novocain-epinephrin. 

Many  of  the  late  recurrences  in  the  skin  can  be  removed  under 
local  anesthesia.  There  is  often  much  scar  tissue  about  these 
recurrent  nodules,  and  it  is  therefore  necessary  to  infiltrate  ex- 
tensively, about  them  in  order  that  the  nerves  may  be  blocked 
before  they  enter  the  scar  area. 


CHAPTER  XII 
OPERATIONS  ON  THE  THORAX,  LUNGS,  SPINE  AND  KIDNEYS 

During  my  student  days  it  was  my  misfortune  to  witness  three 
deaths  upon  the  operating  table  of  patients  being  operated  upon 
for  empyema  or  lung  abscess.  Because  of  this  my, early  efforts 
were  directed  toward  the  perfection  of  a  technic  for  all  opera- 
tions involving  the  thoracic  cavity.  From  this  experience  I  be- 
lieve one  is  justified  in  saying  that  general  anesthesia  is  not  re- 
quired in  operations  upon  the  thorax. 

When  one  considers  the  state  of  the  patients  demanding  such 
operations,  it  is  readily  understood  that  in  no  class  of  operations 
is  a  general  anesthetic  more  often  contraindicated.  The  displace- 
ment of  the  heart  in  intrathoracic  accumulations,  the  embarrass- 
ment of  respiration  and  the  general  septic  condition  of  the 
patient,  all  make  inhalation  anesthesia  hazardous. 

The  demands  on  the  resources  of  the  operator  are  sometimes 
great,  though  fortunately  the  majority  of  operations  are  simple. 
Simple  rib  resection  requires  little  skill,  the  drainage  of  lung 
abscesses  decidedly  more  and  complex  rib  resections  with  the 
associated  scar  formation  may  try  the  skill  of  the  experienced. 

NERVE  SUPPLY. — The  skin  in  the  region  of  the  spine  and  the 
subjacent  muscles  are  supplied  by  the  primary  dorsal  division 
of  the  spinal  nerves.  The  lateral  and  anterior  portions  of  the 
thorax  are  supplied  by  the  intercostal  nerves.  These  represent 
the  anterior  division  of  the  thoracic  nerves  (Fig.  60).  They 
travel,  in  the  first  part  of  their  course,  immediately  beneath  the 
parietal  pleura.  In  the  axillary  line  they  pierce  the  internal 
intercostal  muscle  and  travel  in  the  space  between  the  two 
muscles  to  near  the  sternum.  At  about  the  middle  of  their 
course  they  give  off  a  cutaneous  branch  which  supplies  the  skin 
in  the  lower  part  of  the  chest,  while  in  the  upper  part  of  the  chest 

141 


142  Surgical  Operations  with  Local  Anesthesia 


Fig.  fiO.     Nerve  supply  of  the  abdominal  wall. 


Surgical  Operations  with  Local  Anesthesia 


143 


the  clavicular  and  acroniial  nerves  supply  the  skin.     The  nerves 
terminate  over  the  sternum  and  supply  the  skin  in  this  region. 

OPERATIONS  UPON  THE  SPINE. — Because  of  the  danger  or  em- 
barassment  to  respiration  likely  to  ensue  when  operating  upon 
injuries  to  the  vertebra  in  the  upper  dorsal  region,  local  anesthe- 
sia is  particularly  to  be  desired.  The  depth  of  the  object  of  the 
attack  furnishes  the  chief  difficulty.  The  physical  build  of  the 
patient  permits  us,  therefore,  to  predict  the  difficulties  to  be 
encountered.  The  freest  access  possible  must  be  aimed  at. 


Fig.  61.     Infiltration  of  the  deeper  layers  in  laminectomy. 

This  may  be  achieved  by  infiltrating  with  quinine  a  line  for 
six  inches  over  the  spinous  processes  in  the  region  affected. 
Through  this  line  the  muscles  about  and  lateral  to  the  spinous 
processes  are  extensively  infiltrated  with  a  weak  solution  of  novo- 
cain-epinephrin.  This  blocks  the  posterior  root  of  the  thoracic 
nerves  (Fig.  61)  and  the  action  of  the  epinephrin  secures  a  rela- 
tively bloodless  field.  The  needle  should  be  gradually  pushed  for- 
ward until  the  ligaments  are  reached.  These  can  be  infiltrated 


144 


Surgical  Operations  with  Local  Anesthesia 


without  injuring  the  cord.  The  usual  operations  may  then  be 
performed,  since,  like  the  brain,  the  spinal  cord  and  its  coverings 
are  not  sensitive. 

Like  the  operations  upon  the  brain,  too,  the  patient  may  be 
annoyed  by  the  manipulations  of  the  bony  parts.  For  this  reason 
the  chisel  must  be  eschewed  and  cutting  forceps  substituted. 


Fig.  62.     Author's  laminectomy  trephine.     It  is  made  by  removing  3-5  of 
the  cutting  edge  of  an  ordinary  1J4  inch  trephine. 

A  large,  powerful  Dahlgren  forceps  is  most  suitable.  In  order 
to  avoid  even  so  much  jarring  I  have  devised  a  trephine  for  cut- 
ting the  arches  (Fig.  62).  The  spinous  processes  are  removed 
and  the  arches  are  then  cut,  first  on  one  side  and  then  on  the 
other.  When  this  has  been  done  the  arch  may  be  lifted  out. 
This  method  has- the  advantage  in  that  the  spinal  roots  are  not 
interfered  with,  as  is  the  case  when  cutting  forceps  are  used. 
THORACOPLASTIES. — When  a  considerable  area  is  to  be  re- 


Surgical  Operations  zvith  Local  Anesthesia 


145 


moved,  as  in  rib  tuberculosis  or  thoracoplasties,  it  is  best  to  block 
the  intercostal  nerves  in  continuity.  This  is  best  done  at  the  angle 


Fig.  63.     The  line  of  circles  represents  the  skin  infiltrations  ;  the  marks,  x 
indicate  the  points  at  which  the  intercostal  nerves  are  blocked. 

of  the  ribs.     The  rib  is  located  with  the  tip  of  the  index  finger 
and  the  needle  pushed  through  the  skin  just  above  the  guiding 


146  Surgical  Operations  zvith  Local  Anesthesia, 

finger  into  the  interspace.  The  nerves  lie  upon  the  parietal 
pleura,  and  the  nearer  the  point  of  the  needle  lies  to  this  region 
when  the  solution  is  expelled,  the  more  prompt  and  certain  the 
anesthesia.  The  trained  finger  can  usually  feel  when  the  needle 
has  reached  the  resistance  offered  by  the  pleura.  Usually  the 
patient  experiences  some  pain  expressed  by  contraction  of  the 
spinal  muscles  when  this  region  is  reached.  Two  cc.  of  the 
anesthetic  solution,  preferably  a  i  per  cent,  novocain-epinephrin, 
is  deposited  at  this  point.  The  number  of  nerves  that  must  be 
blocked  is  dependent  upon  the  extent  of  the  operation.  In 
thoracoplasties,  usually  five  or  six  must  be  blocked.  In  the  re- 
moval of  a  diseased  rib  two  usually  suffices. 

In  thoracoplasties  the  skin  is  now  infiltrated  in  the  line  in 
which  the  skin  incision  is  to  be  made  (Fig.  63).  Additional 
blocking  in  the  intercostal  spaces  are  made  through  this  line  to 
avoid  pain  through  anastomosis  with  nerves  not  previously 
blocked. 

The  thoracic  wall  may  now  be  attacked  in  any  manner  desired. 
The  visceral  pleura  is  not  anesthetized,  and  if  decortication  of 
the  lung  is  to  be  added  a  general  anesthetic  must  be  resorted  to. 
These  are  formidable  operations  at  best  and  only  the  experienced 
technician  is  warranted  in  attempting  them. 

RIB  RESECTION. — Inasmuch  as  the  less  experienced  in  technic 
are  likely  to  be  called  upon  to  do  limited  resections  of  a  single 
rib,  this  technic  may  be  described  in  detail. 

Inasmuch  as  the  resection  of  a  rib  presupposes  an  accurate 
knowledge  of  the  character  of  the  exudate,  the  technic  of  explor- 
atory puncture  may  be  given.  Simple  as  the  procedure  is,  unnec- 
essary pain  is  too  often  inflicted.  This  may  be  a  matter  of  im- 
portance with  patients  who  must  be  subjected  to  repeated  punc- 
tures. 

An  ordinary  hypodermic  syringe  fitted  with  a  standard  needle 
is  sufficient  if  the  thoracic  wall  is  thin,  but  in  many  cases  a  longer 
needle  is  required.  The  caliber  of  the  needle  required  is  depend- 
ent upon  the  character  of  the  exudate.  In  fresh  exudations  a 


Surgical  Operations  with  Local  Anesthesia  147 

fine  needle  is  satisfactory,  but  in  long  standing  exudates  or  puru- 
lent effusions  a  larger  bore  is  required.  A  syringe  capable  of 
being  boiled  with  the  needle  should  be  employed,  but  if  such  can 
not  be  obtained,  the  needle  should  be  boiled  and  the  syringe  chem- 
ically sterilized,  preferably  with  formalin  or  iodine.  The  skin 
may  most  conveniently  be  prepared  by  painting  with  tincture  of 
iodine  or  by  washing  with  soap  and  water  followed  by  alcohol. 
Many  practitioners  use  no  anesthetic  in  making  the  puncture;  a 
local  anesthetic  removes  the  pain  during  and  after  the  operation. 
Freezing  effectually  prevents  pain  in  the  skin  from  the  initial 
prick,  but  the  effect  is  evanescent  and  it  is  followed  by  after- 
pain.  Salt  and  ice  pressed  against  the  skin  for  a  minute  or  two 
lessens  the  sensibility  to  a  considerable  degree.  Neither  of  these 
methods  produces  an  anesthesia  lasting  long  enough  to  permit 
careful  exploration.  Injection  anesthesia  is,  therefore,  prefer- 
able because  it  not  only  permits  the  operator  to  study  the  char- 
acter of  tissue  through  which  the  needle  passes,  but  if  therapeutic 
measures  are  to  follow,  the  operation  may  proceed  at  once. 
Quinine,  because  of  its  efficiencv  and  the  duration  of  its  effect, 
is  the  most  suitable  substance.  Ten  or  twenty  minims  of  I  per 
cent,  solution  is  drawn  into  the  syringe,  a  fold  of  skin  over  the 
intercostal  space  in  which  the  puncture  is  to  be  made  is  caught 
up  between  the  thumb  and  forefinger  so  that  it  becomes  anemic 
and  thus  less  sensitive.  The  needle  is  made  to  penetrate  the  skin 
at  a  slight  angle  and  a  few  drops  of  the  fluid  are  deposited  in 
the  skin.  The  needle  is  then  gradually  forced  inward  imme- 
diatelv  above  the  next  rib  below  in  order  to  avoid  the  intercostal 
vessels  which  lie  in  the  groove  of  the  upper  rib.  As  the  needle 
reaches  the  pleura  the  resistance  is  increased  or  the  patient 
experiences  slight  pain.  The  remainder  of  the  anesthetic  fluid 
in  the  syringe  is  deposited  at  this  point.  An  interval  of  a  few 
seconds  permits  anesthesia  to  become  effective  and  the  needle 
may  then  be  pressed  into  the  pleural  cavity,  whereupon  the  resist- 
ance is  suddenly  lessened.  The  syringe  is  then  steadied  with  the 
left  hand  while  the  right  gradually  withdraws  the  piston.  If 


148  Surgical  Operations  -with  Local  Anesthesia 

fluid  is  present  it  should  appear  in  the  barrel  of  the  syringe.  If 
no  fluid  appears,  it  is  either  absent  or  the  needle  may  be  too  short 
to  enter  the  thoracic  cavity,  or  the  fluid  may  be  too  thick  to  pass 
through  the  needle.  If  no  fluid  is  present  the  needle  can  be  felt 
to  strike  the  visceral  pleura  and  usually  the  patient  complains 
of  pain.  If  there  is  doubt  about  the  needle  entering  the  cavity, 
a  longer  one  should  be  employed.  If  the  physical  findings  for 
fluid  are  definite  and  the  case  is  of  long  duration,  the  possibility 
of  a  fluid  too  thick  to  pass  the  needle  must  be  entertained  and  a 
needle  of  larger  caliber  employed.  Adhesions  at  the  site  of  punc- 
ture may  give  a  negative  aspiration.  In  that  event  the  same  pro- 
cedure must  be  repeated  in  other  likely  situations.  If  the  site 
of  an  adhesion  is  punctured,  the  needle  enters  the  lung,  which  is 
manifest  by  the  entrance  into  the  syringe  of  bubbles  of  air  cov- 
ered with  blood. 

THORACENTESIS. — The  correctness  of  the  diagnosis  having  been 
demonstrated  by  exploratory  puncture,  the  question  of  the  re- 
moval of  the  fluid  must  be  decided.  This  may  be  best  undertaken 
at  the  time  of  the  exploratory  puncture  for  it  saves  the  patient 
a  second  annoyance  and  the  doctor  a  second  preparation.  The 
clinical  diagnosis  should  be  sufficiently  accurate  to  determine  the 
character  of  apparatus  which  will  be  required.  The  exact  poin; 
where  fluid  will  be  obtained  is  known.  A  tract  for  the  aspira- 
ting needle  in  case  aspiration  alone  is  needed  is  already  anesthe- 
tized, the  interval  between  the  puncture  and  the  aspiration  per- 
mitting perfect  anesthesia  to  take  place. 

In  the  absence  of  more  suitable  apparatus  a  syringe  holding  a 
few  drams,  and  fitted  with  a  stop-cock  may  be  employed.  It  is 
a  slow  method  and  is  trying  to  both  patient  and  operator,  but  it 
is  possible  to  remove  large  accumulations  with  this  simple  appara- 
tus. The  most  suitable  apparatus  is  the  Potain  aspirator. 

All  apparatus  which  comes  in  contact  with  the  patient  should 
be  prepared  by  boiling.  The  hand  of  the  operator  should  not 
touch  that  portion  of  the  needle  which  is  to  enter  the  tissue.  The 
needle  is  passed  along  the  tract  of  the  exploratory  puncture 


Surgical  Operations  with  Local  Anesthesia  149 

already  anesthetized,  and  this  may  be  accomplished  without  pain. 
If  the  needle  is  none  too  sharp,  it  is  often  desirable  to  nick  the 
skin  with  a  scalpel  so  as  to  avoid  an  annoying  degree  of  pressure. 
The  preliminary  use  of  the  scalpel  is  particularly  indicated  when 
a  trocar  is  used.  When  the  parietal  pleura  is  passed  aspiration 
may  begin. 

Whether  all  the  fluid  obtainable  is  to  be  withdrawn  at  the 
first  aspiration  depends  on  circumstances.  In  neglected  cases 
when  a  considerable  amount  of  fluid  is  withdrawn,  a  temporary 
irritation  indicated  by  coughing  may  attend  the  expansion  of  the 
lungs,  or  the  replacement  of  the  heart  to  its  normal  position  may 
cause  a  sense  of  faintness.  Either  of  these  sensations  if  at  all 
marked  should  be  a  signal  to  the  operator  to  desist.  In  early 
cases  the  first  evidence  of  discomfort  is  shown  when  the  fluid 
is  nearly  all  removed  and  the  expanding  lung  causes  the  visceral 
pleura  to  came  in  contact  with  the  end  of  the  aspirator.  This 
pain  can  often  be  relieved  by  withdrawing  the  needle  or  by  tilt- 
ing the  tip  downward.  When  the  operation  is  ended  the  aspirator 
is  withdrawn  and  the  wound  is  closed  with  gauze  and  collodion 
or  adhesive  plaster.  If  it  is  necessary  to  interrupt  the  aspiration 
before  the  fluid  is  all  withdrawn,  the  operation  should  be  repeated 
after  an  interval  of  a  few  days. 

PERMANENT  DRAINAGE. — Purulent  fluid  requires  a  permanent 
exit.  In  children  this  is  satisfactorily  accomplished  by  the  intro- 
duction of  a  fair  sized  (say  26  F)  soft  rubber  catheter  through 
a  simple  intercostal  incision.  Sometimes  the  catheter  is  pushed 
through  the  sleeve  of  a  large  trocar,  after  which  the  latter  is 
withdrawn.  It  is  often  possible  to  employ  this  method  under 
local  anesthesia  in  quite  young  children.  It  is  especially  efficient 
also  when  permanent  suction  is  to  be  applied  to  the  drainage 
tube.  Permanent  suction  has  been  accomplished  in  various 
ways.  The  simplest  method  is  by  the  permanent  application  of 
a  Potain  aspirator,  the  negative  pressure  in  the  receiving  bottle 
being  kept  at  the  point  of  easy  tolerance. 

RIB  RESECTION. — In  empyema  in  older  persons,  the  resection  of 


150  Surgical  Operations  with  Local  Anesthesia 

a  rib  is  necessary,  in  order  to  secure  satisfactory  drainage.  The 
diagnosis  is  less  certain  than  in  case  of  serous  effusion  by  physi- 
cal means  alone.  Before  operation  it  is  always  advisable  to  verify 
the  diagnosis  by  puncture. 

The  resection  of  a  rib  is  a  simple  operation,  but  since  it  is 
always  done  upon  a  dyspneic  patient,  the  complications  are  often 
annoying.  Instruments  sufficient  to  meet  all  possible  emergen- 
cies should  always  be  at  hand.  Aside  from  the  usual  syringe 
and  solution  for  local  anesthesia,  a  rib  shears  or  a  bone  cutting 
forceps,  a  periosteal  elevator,  knife,  scissors  and  a  number  of 
hemostats  and  a  needle  threaded  with  catgut  should  be  provided. 


Fig.  64.     Injection  of  intercostal  nerve.     The  needle  passes  close 
under  the  lower  border  of  the  rib. 

The  latter  may  be  needed  should  the  intercostal  vessels  be  inad- 
vertently severed. 

The  site  of  operation  is  selected,  usually  the  7th  or  8th  rib  at 
the  mid-axillary  line.     A  line  of  skin  3  inches  long  is  injected 


Surgical  Operations  with  Local  Anesthesia  151 

over  and  parallel  with  the  rib  selected  for  removal.  The  area 
immediately  beneath  the  rib  at  both  ends  of  the  line  of  injec- 
tion is  infiltrated  in  such  a  manner  as  to  deposit  a  pool  of  fluid 


Fig.  65.     Partial  elevation  of  the  periosteum. 


Fig.  6fi.      Elevation  of  the  periosteum  completed    the  rib  is  removed 
and  the  parietal  pleura  incised. 

about  the  intercostal  nerve  (Fig.  64).  Next  the  periosteum 
over  the  rib  is  freely  injected.  A  wait  of  a  few  minutes 
permits  anesthesia  to  take  place.  An  incision  is  made  through 
the  skin  the  length  of  the  line  infiltrated.  The  muscle  over  the 


152  Surgical  Operations  with  Local  Anesthesia 

rib  is  next  incised.  All  hemorrhage  should  be  controlled  at  this 
point.  The  periosteum  over  the  rib  is  then  incised  for  a  dis- 
tance of  two  inches.  The  periosteum  is  elevated  from  the  rib 
about  its  entire  circumference,  care  being  taken  to  remove  it 
from  the  groove  containing  the  intercostal  vessels  (Fig.  65). 
The  pleural  surface  of  the  periosteum  must  not  be  perforated. 
The  periosteum  being  loosened  for  the  entire  distance  of  the 
incision,  the  rib  may  be  cut.  At  least  an  inch  should  be  re- 
moved. The  opening  thus  made  has  for  its  floor  the  parietal 
periosteum.  If  the  intercostal  vessels  have  been  cut  they  may 
be  controlled  by  mass  ligatures  through  the  muscle.  When 
all  hemorrhage  has  been  checked  the  drainage  tubes  are  made 
ready,  the  periosteum  is  quickly  incised  (Fig.  66)  and  the  tubes 
passed  into  the  opening.  The  tubes  must  be  sutured  to  the  skin 
in  order  to  prevent  their  slipping  into  the  thorax.  Many  opera- 
tors permit  the  pus  to  flow  out  before  a  dressing  is  applied,  others 
prefer  to  apply  a  large  snug  dressing  quickly  and  permit  the  pus 
gradually  to  soak  into  it. 

If  the  parietal  periosteum  is  inadvertently  opened  the  pus  flows 
at  once  and  the  cutting  of  the  rib  and  the  control  of  any  hemor- 
rhage that  may  ensue  must  be  done  in  a  puddle  of  pus. 

The  duration  of  the  quinine  anesthesia  is  such  that  nothing  is 
required  for  post-operative  pain.  The  dressings  must  be  removed 
as  they  become  soiled.  After  the  flow  has  lessened  the  tubes  are 
gradually  shortened  and  can  usually  be  removed  in  from  2  to  6 
weeks,  depending  on  the  nature  of  the  infection,  the  earlier  period 
if  the  pneumococcus  or  influenza  bacillus  is  the  infective  agent, 
the  longer  if  the  empyema  is  secondary  to  some  infection  of  the 
abdomen  or  pelvis. 

DRAINAGE  OF  LUNG  ABSCESSES. — There  is  no  operation  that  de- 
mands so  much  of  the  operator  as  the  drainage  of  lung  abscesses. 
The  greatest  difficulty  lies  in  locating  them.  This  can  be  proven 
only  by  exploratory  puncture.  Pus  macroscopic  in  amount  may 
not  be  encountered  and  cultures  must  be  made  from  the  serum 
obtained.  Every  provision  must  be  made  for  a  bacterial  exami- 
nation. 


Surgical  Operations  with  Local  Anesthesia  153 

The  abscess  is  located  as  nearly  as  possible  by  the  physical 
signs.  At  the  most  accessible  point  the  skin  is  infiltrated  as  for 
puncture  of  the  pleura.  When  the  tract  has  become  fully  anes- 
thetized a  needle  of  sufficient  size  and  caliber  is  used  to  search 
for  the  abscess.  When  the  parietal  pleura  is  reached  the  resist- 
ance is  appreciated  and  its  thickness  is  determined  by  the  resist- 
ance offered.  If  pain  is  perceived  a  few  drops  of  an  anesthetic 
fluid  may  be  injected  when  the  visceral  pleura  is  penetrated. 
This  makes  the  subsequent  procedures  more  satisfactory  if  re- 
peated punctures  are  required. 

The  actual  search  for  the  abscess  in  the  depth  of  the  lung  is 
now  begun.  The  increased  lung  resistance  is  often  a  clue  that 


Fig.  67.     Author's  dilator  for  widening  the  tract  to  permit  the 
introduction  of  the  drainage  tube. 


the  abscess  is  being  approached.  When  a  cavity  exists  and  the 
needle  enters,  the  sudden  lessened  resistance  is  perceived.  If  pus 
is  present  it  may  be  withdrawn.  Often  no  actual  cavity  is  en- 
tered but  the  needle  may  penetrate  pus  infiltrated  tissue.  In  that 
event  a  few  drops  of  bloody  serum  may  be  all  the  operator 
obtains.  Bacteriological  examination  may  reveal  the  presence  of 
pus  microbes.  Often  repeated  punctures  must  be  made  before 
the  abscess  is  located.  The  needle  must  be  redrawn  each  time 
until  the  point  is  just  within  the  visceral  pleura  and  then  intro- 
duced with  a  change  of  direction.  Only  in  gross  interpretations 
of  the  physical  signs  is  it  necessary  to  entirely  withdraw  the 
needle. 


154  Surgical  Operations  with  Local  Anesthesia 

When  the  pus  is  located,  the  exploring  needle  should  be  left 
in  situ  and  a  rib  resected  as  explained,  above.  When  the  pleura 
has  been  opened  the  needle  may  be  followed  by  a  closed  artery 
forceps  in  order  to  secure  an  opening  large  enough  to  admit  a 
drain.  Better  still  is  the  instrument  devised  by  me  for  this  pur- 
pose. The  needle  is  straddled  with  the  instrument  (Fig.  67) 
which  is  then  forced  through  the  lung  until  its  tip  enters  the 
abscess.  The  blades  are  then  separated,  the  needle  withdrawn 
and  a  drainage  tube  substituted  and  the  instrument  withdrawn. 
This  permits  the  tube  to  be  introduced  more  quickly  than  if  the 
dilatation  is  made  with  forceps. 

If  the  pleural  space  is  not  obliterated  by  the  adhesions  of  the 
parietal  and  visceral  pleura,  the  area  must  be  packed  for  a  few 
days  until  obliteration  does  take  place.  It  is  often  possible  to 
determine  if  the  visceral  and  parietal  pleura  are  adherent  by  the 
sensation  imparted  to  the  needle  when  it  is  passing  from  the  one 
to  the  other.  If  there  are  no  adhesions  the  movement  of  the 
lung  will  be  felt  by  the  tug  upon  the  needle.  This  method  is  by 
no  means  a  certain  test  and  is  only  after  a  rib  has  been  resected 
and  the  pleura  opened  that  any  reliable  information  is  obtainable. 
If  there  is  a  free  space  the  opening  in  the  parietal  pleura  is  packed 
with  plain  gauze  in  such  a  manner  that  it  comes  in  contact  with 
the  visceral  pleura,  thus  exciting  adhesions.  Reliable  adhesion ; 
will  have  formed  in  3  or  4  days.  The  method  of  obliterating 
the  space  by  suture  is  not  suited  to  local  anesthesia  and  is  ob- 
jectionable because  immediate  suture  does  not  protect  the  pleural 
cavity  with  certainty  from  infection  if  the  abscess  be  drained  at 
once. 

The  opening  of  lung  abscesses  following  pneumonia  offers 
no  difficulties  under  local  anesthesia.  Those  following  prolonged 
suppxirative  processes  in  the  pelvis  or  abdomen  in  which  the 
patient  is  often  pus  soaked  for  many  months  and  usually  more 
or  less  accustomed  to  the  use  of  morphine,  are  not  favorable 
cases  for  local  anesthesia.  Unless  the  operator  is  experienced 
both  in  the  treatment  of  lung  abscesses  and  in  thoracic  operations 


Surgical  Operations  with  Local  Anesthesia  155 

under  local  anesthesia,  he  will  do  better  to  place  the  additional 
burden  of  a  general  anesthetic  upon  the  patient. 

DRAINAGE  OF  suBDiAPHRAGMATic  ABSCESSES. — The  technic  re- 
quired does  not  differ  from  that  described  for  lung  abscess.  A 
rib  must  be  resected  and  the  pleural  cavity  protected  if  pleural 
adhesions  have  not  already  taken  place.  After  the  necessary 
opening  has  been  made  in  the  chest  wall  no  further  anesthetiza- 
tion is  required.  The  abscess  is  located  with  a  needle  and  the 
drainage  tube  introduced  as  in  lung  abscess.  On  the  whole  the 
location  and  drainage  of  these  abscesses  is  much  more  easily 
accomplished  than  drainage  of  lung  abscesses. 


OPERATIONS  ON  THE  MEDIASTINUM 

The  recent  advances  in  the  diseases  involving  the  thymus 
make  operations  in  this  region  a  matter  of  practical  interest. 
A  bloodless  field,  which  the  use  of  epinephrin  assures,  is  par- 
ticularly desirable,  in  order  that  the  operators'  orientation  may 
not  be  disturbed  when  operating  in  a  field  so  full  of  important 
structures.  Fortunately,  the  nerve  supply  to  this  region  is 
such  that  the  technic  of  local  anesthesia  is  relatively  easy. 

The  mediastinum  is  best  approached  from  one  side  rather 
than  through  the  body  of  the  sternum.  By  removing  the  car- 
tilages of  as  many  ribs  as  may  be  necessary  a  wide  opening 
may  be  secured.  To  approach  the  mediastinum  by  deepening 
the  suprasternal  notch  is  inadvisable,  since  at  best  it  gives  in- 
adequate room,  and  it  compels  the  operator  to  approach  im- 
portant structures  without  an  adequate  chance  for  the  proper 
determination  of  their  relations. 

The  technic  I  have  employed  is  as  follows :  the  preliminary 
line  of  skin  infiltration  is  made  horseshoe-shaped,  with  the  open 
end  upward  (Fig.  68).  One  limb  of  the  horseshoe  is  placed 
just  lateral  to  the  sternal  border  on  the  side  opposite  that  to 
be  attacked.  The  limb  on  the  side  from  which  the  mediastinum 


156 


Surgical  Operations  rvith  Local  Anesthesia 


is  to  be  entered  is  placed  over  the  line  where  the  ribs  are  to 
be  severed  which  is  usually  at  the  costo-chondral  junction.  This 
infiltration  is  made  with  quinine  for  the  purpose  of  limiting 
the  use  of  the  novocain-epinephrin  solution.  Novocain-epine- 
phrin  is  used  for  infiltration  of  the  mediastinal  space  itself,  and 
for  the  blocking  of  the  intercostal  nerves. 

From    this   primary    line   the    intercostal   nerves    are    blocked 


Fig.  ttS.     Line  of  skin  infiltration  :     a.  n,  points  for  blocking  the  intercostal  nerves  ; 

l>,  ii,  infiltration  of  the  suprasternal  space  and  blocking  of  the  cervical  nerves ; 

c,  infiltration  of  the  upper  retrosternal  tissues  ;  and  e,  infiltration 

of  the  mid-retrosternal  tissues. 

and  the  periosteum  of  the  ribs  is  anesthetized  by  injecting  the 
solution  about  them.  It  is  not  necessary  to  inject  the  fluid 
beneath  the  periosteum,  because  if  the  fluid  is  injected  about 
the  periosteum  the  nerves  will  be  blocked  before  they  reach 
this  structure.  Each  intercostal  space  in  turn  is  so  injected 
(a,  a,  Fig.  68).  The  operator  must  remember  that  the  nerves 
lie  just  below  the  border  of  the  ribs.  Usually  the  line  of 
section  of  the  ribs  is  at  the  costo-chondral  junction,  and  the 


Surgical  Operations  with  Local  Anesthesia  157 

skin  line  is  made  here.  By  passing  the  needle  through  the 
primary  line  and  directing  it  outward  and  backward  the  nerve 
may  be  reached,  as  it  lies  beneath  the  rib. 

The  periosteum  of  the  sternum  is  blocked  by  injecting  fluid 
over  it  from  the  primary  line  of  infiltration.  This  is  readily 
accomplished  if  a  sufficiently  long  needle  is  used.  The  cervical 
nerves  must  receive  special  attention.  These  may  best  be 
reached  by  making  extensive  subcutaneous  injections  from  the 
upper  end  of  each  limb  of  the  primary  lines  of  the  infiltration 
(b,  d,  Fig.  68).  This  blocks  all  nerves  coming  from  the  cervical 
plexus.  While  this  is  being  done,  it  is  convenient  to  infiltrate 
the  loose  tissues  of  the  jugulum  (c,  Fig.  68).  At  the  upper 
limb  of  the  horseshoe  on  each  side  the  needle  is  passed  cau- 
tiously behind  the  sterno-clavicular  articulation.  The  tissues 
in  this  situation  are  little  sensitive,  but  several  cc.  of  the  ^2% 
novocain-epinephrin  solution  should  be  used  in  order  to  secure 
complete  constriction  of  the  small  vessels  in  this  region.  The 
retrosternal  tissues  behind  the  body  of  the  bone  may  be  reached 
by  passing  the  needle  close  to  the  bone  from  each  of  the  inter- 
costal spaces  (e,  Fig.  68). 

In  making  these  deeper  injections,  when  large  vessels  are 
approached,  it  is  well  to  use  as  fine  a  needle  as  possible,  and 
to  introduce  it  carefully  with  the  empty  syringe  attached  in 
which  the  piston  has  been  drawn  partly  back  so  that  a  vacuum 
is  created.  If  a  vessel  is  perforated,  blood  at  once  appears  in 
the  syringe.  If  none  appears  the  operator  may  feel  safe  in 
injecting  the  fluid  as  soon  as  the  needle  has  reached  the  desired 
depth.  This  maneuver  is  repeated  as  often  as  is  necessary  to 
infiltrate  the  entire  area. 

The  parietal  pleura  comes  close  to  the  border  of  the  sternum, 
and  the  operator  must  hug  the  parietal  fascia  in  order  to 
reach  the  mediastinum  without  entering  the  pleural  cavity.  The 
operator's  sense  of  touch  must  guide  him  in  this  maneuver. 

If  the  needle,  such  as  is  used  for  this  purpose,  does  acci- 
dentally perforate  the  pleura,  the  puncture  is  not  large  enough 


158  Surgical  Operations  with  Local  Anesthesia 

to  admit  air.  If  the  needle  perforates  a  vein  some  oozing 
occurs  when  the  needle  is  withdrawn,  but  it  soon  stops.  If  an 
artery  is  perforated  a  tiny  geyser  forms  for  a  few  seconds, 
but  this  soon  ceases. 

The  incision  is  made  down  the  line  of  infiltration,  on  the  side 
from  which  the  mediastinum  is  to  be  approached,  and  extended 
across  the  sternum  below.  If  the  upper  portion  of  the  sternum 
and  the  jugulum  is  to  be  reached  the  incision  may  be  extended 
across  above  (Fig.  68).  The  flap  is  loosened  and  reflected.  The 
cartilages  and  sternum  are  carefully  separated  from  the  parietal 
pleura.  The  use  of  epinephrin  lessens  the  oozing  to  a  surpris- 
ing extent,  and  with  care  the  entire  series  of  cartilages  and 
sternum  may  be  so  separated  before  the  rongeur  is  used  to 
remove  the  osseous  structures.  The  internal  mammary  vessels 
are  pushed  out  of  the  way  and  do  not  require  ligation. 

Should  the  pleura  be  inadvertently  opened,  the  hole  may  be 
compressed  with  pledgets  of  gauze  until  the  operator  is  pre- 
pared to  close  the  opening.  If  an  abscess  is  to  be  attacked, 
it  may  be  well  to  pack  gauze  into  the  pleural  cavity  and  await 
the "  formation  of  adhesions  before  the  operation  is  completed. 
This  procedure  could  be  desirable  only  in  the  presence  of  sup- 
purative  processes. 

It  has  been  my  experience  to  open  the  pleura  in  several  in- 
stances, but  the  patient  experiencd  but  little  inconvenience  and 
no  distress.  The  opening  can  be  sutured  or  packed  at  once. 


OPERATIONS  ON  THE  KIDNEYS  AND  URETERS. 

The  essentials  in  the  operations  on  the  kidneys  and  ureters 
consist  of  an  effective  blocking  of  the  XII  thoracic  and  the 
first  three  lumbar  nerves.  The  field  of  operation  receives 
aberrant  twigs  from  nerves  lying  above  and  below  this  region. 
It  is  well,  therefore,  to  anticipate  their  presence  by  infiltrating 
the  skin  about  the  limits  of  the  field  of  operation  (Fig.  69). 


Surgical  Operations  with  Local  Anesthesia 


159 


The  trunks  above  indicated  are  best  reached  by  passing  the 
needle    about    midway    between    the    spinous    processes.      This 


•''- 

;  m 


-^-v^jv; 

•}$ 
# 


Fig.  69.     Line  of  skin  infiltration  preliminary  to  operations  on  the  kidney 
and  ureter ;  x,  x,  points  at  which  the  needle  is  introduced 
in  blocking  the  nerve  trunks. 

point   is   reached   by   passing  the   needle   forward  and   medially 
from  a  line  4  or  5  cm.  lateral  to  the  midline  opposite  the  upper 


160  Surgical  Operations  with  Local  Anesthesia 

edge  of  the  spinous  process  corresponding  to  the  nerve  sought. 
The  nerves  lie  about  on  the  level  of  the  lower  border  of  the 
transverse  processes  (compare  Fig.  70),  and  from  i  to  il/2 
cm.  deeper.  It  is  well  to  deposit  5  cc.  of  a  i%  novocain-epine- 
phrin  solution  in  this  region.  In  addition,  the  tissues  of  the 
abdominal  wall  may  be  infiltrated  by  a  weaker  solution  (5/2 
to  /4%)  along  the  line  of  the  proposed  incision.  If  the  block- 
ing of  the  nerves  above  indicated  is  well  done,  this  step  would 
not  be  necessary,  but  the  operator's  marksmanship  may  be 
defective,  particularly  in  fat  patients.  The  loose  perirenal  tissue 
may  be  infiltrated  with  a  weak  anesthetic  solution,  though  this 
is  scarcely  necessary. 

Traction  on  the  kidney  causes  some  pain.  It  is  well,  therefore, 
to  have  an  incision  long  enough  so  that  complete  dislocation  of 
the  organ  will  not  be  necessary.  Incision  into  the  kidney  is 
not  painful,  but  exploration  of  the  pelvis  is  painful.  In  the 
case  of  palpable  stone,  it  is  well,  therefore,  to  make  direct 
incision  into  the  pelvis  after  infiltrating  the  wall. 

The  ureter  may  be  followed  from  the  kidney  by  raising  the 
peritoneum  the  required  distance.  When  the  stone  is  palpated, 
it  is  well  to  infiltrate  the  ureter  before  the  extraction  of  the 
stone  is  undertaken.  The  chief  requirement  in  ureteral  opera- 
tions is  an  adequate  incision  through  the  abdominal  wall,  in 
order  to  avoid  undue  tugging  on  the  peritoneum.  For  this 
reason  the  v.  Bergmann  incision,  downwards  and  forwards,  is 
preferable,  even  when  the  kidney  alone  is  to  be  attacked.  Skill 
in  renal  surgery  is  the  prime  requisite  in  performing  this 
operation. 


CHAPTER  XIII 
ABDOMINAL  OPERATIONS 

Operations  upon  the  abdominal  wall  may  now  be  said  to  behx.g 
definitely  to  the  domain  of  local  anesthesia.  Operations  upon  the 
abdominal  contents  belong  distinctively  as  yet  to  the  domain  of 
general  anesthesia.  There  are,  however,  many  surgical  condi- 
tions within  the  abdomen  which  may  be  regarded  as  belonging 
on  the  border  line  and  may  under  special  indications  be  satis- 
factorily performed  under  local  anesthesia.  The  unfitness  of 
local  anesthesia  for  most  intra-abdominal  operations  is  due  in 
part  to  the  multiplicity  of  the  nerve  supply,  in  part  to  inaccessi- 
bility of  the  actual  field  of  operation ;  but  chiefly  to  the  fact  that 
on  account  of  the  various  manifestations  of  reactive  processes,  it 
it  impossible  to  predict  the  condition  in  which  the  organs  will 
be  found,  and  consequently  to  foresee  the  extent  of  the  operation. 
An  adequate  nerve  control  of  the  abdominal  contents  would  in- 
volve blocking  all  the  vertebral  nerves.  Kappis  (Munch.  Med. 
Woch.,  1912,  No.  15)  has  proposed  the  blocking  of  the  V  to  XII 
dorsal  nerves  and  the  I  to  III  lumbar  nerves.  The  principle- 
is  correct,  but  difficult  in  practice.  Such  extensive  blocking 
would  have  to  be  done  with  exceeding  accuracy  to  avoid  the 
use  of  a  dangerous  amount  of  anesthetic  solution.  Furthermore, 
blocking  the  spinal  nerves  does  not  interfere  with  the  conductiv- 
ity of  the  sympathetic  nerves.  Attempts  at  blocking  nerves  to 
individual  organs  at  the  roots  of  the  mesenteries  have  not  met 
with  success  because  of  the  thinness  of  the  surrounding  tissue 
which  increases  the  technical  difficulties  very  greatly.  The  results 
attained  in  this  way  are  not  constant  because  sensibility  varies 
considerably  in  different  individuals  and  under  different  condi- 
tions. For  this  reason  enthusiastic  reports  published  on  the  basis 
of  a  few  cases  of  mesenteric  blocking  will  usually  be  discounted 
by  operators  with  a  more  extended  experience.  So  far  as  present 
knowledge  goes,  success  in  abdominal  operations  under  local 
anesthesia  depends  upon  the  proper  selection  of  cases  and  upon 
gentleness  of  technic  after  the  abdomen  is  opened. 

161 


1 62 


Surgical  Operations  with  Local  Anesthesia 


Generally  speaking,  operations  upon  organs  coming  naturally 
in  contact  with  the  abdominal  wall  or  those  which  may  readily 
be  brought  into  contact  with  it  may  be  readily  performed  under 
local  anesthesia.  Organs  which  normally  lie  deeper  and  require 
much  traction  upon  their  mesenteric  attachments  are  less  readily 


•Dorsal  cut  for.  (med) 

r. 'Dorset/  cut-  Jbr. (Ictt.) 


Post.br. 
-~bf  icrferal 
cut  n. 


cut.  I  at 


Fig.  70.     Relation  of  the  abdominal  muscles  and  the  nerves 
supplying  the  abdominal  walls. 

operated  on.  Superficial  organs  which  have  become  abnormally 
attached  as  the  result  of  some  past  inflammation  are  even  less 
suited  to  local  anesthesia,  for  adhesions  may  be  more  sensitive 
and  are  always  less  readily  influenced  by  anesthetics  than  are 
normal  attachments. 


Surgical  Operations  with  Local  Anesthesia  163 

These  conditions  may  be  illustrated  by  the  citation  of  three 
cases  of  gall  bladder  trouble  in  old  women.  The  clinical  pic- 
tures of  these  were  quite  identical  and  indications  for  local 
anesthesia  were  presented  by  advanced  age,  chronic  pulmonary 
affections  and  uncertain  kidney  function.  In  the  one  patient 
when  the  abdomen  was  opened  the  fundus  of  the  gall  bladder 
presented  at  the  incision.  Cautious  palpation  showed  the  com- 
mon duct  to  be  free  from  stones.  The  operation  was  easily 
terminated  by  the  removal  of  the  stones  and  drainage  of  the 
gall-bladder.  The  second  patient  likewise  had  a  common  duct 
free  from  stones,  but  the  gall-bladder  was  small  and  deeply 
situated,  and  could  not  be  brought  near  the  surface.  It  was 
opened  in  situ  and  a  tube  fastened  in  the  opening.  In  the  third 
case,  after  the  abdomen  was  opened,  a  mass  of  adhesions  pre 
sented,  and  careful  palpation  and  inspection  failed  to  disclose 
the  location  of  the  gall-bladder.  Ether  was  given  at  once  before 
the  patient  was  hurt  by  an  attempt  to  locate  the  gall-bladder  by 
the  separation  of  the  adhesions. 

These  difficulties  are  naturally  greater  in  inflammations  in  which 
the  sensitiveness  of  the  organs  is  increased.  The  statement  of 
Braun  that  sensitiveness  is  not  increased  is  true  for  parts  in  the 
hyperemic  stage  of  inflammations,  and  for  adjacent  regions  which 
are  only  reflexly  hyperemic.  In  the  later  stages  of  inflammation 
in  the  presence  of  fibrous  exudate  sensitiveness  is  not  greater  than 
normal  and  may  be  less.  During  the  early  exudative  stages  the 
tissues  are  acutely  sensitive.  For  example,  the  placing  or  removal 
of  abdominal  sponges,  which  is  always  painful,  is  particularly 
so  in  the  presence  of  acute  inflammation.  For  this  reason  opera- 
tions in  acutely  inflamed  regions  not  adjacent  to  the  abdominal 
wall,  which  require  a  safety  packing,  are  not  ordinarily  suitable 
for  local  anesthesia.  However,  where  there  is  a  secondary- 
attachment  of  the  diseased  part  to  the  abdominal  wall,  as  in 
appendiceal  or  gall  bladder  suppurations,  local  anesthesia  finds 
one  of  its  most  gratifying  fields. 

In  operations  upon  abdominal  organs  the  operator  must  be  an 


164  Surgical  Operations  with  Local  Anesthesia 

opportunist.  He  should  approach  his  patient  prepared  to  use  the 
method  of  anesthesia  most  appropriate  to  the  conditions  and  nov 
predetermined  to  see  if  the  operation  can  be  done  under  local 
anesthesia.  If  an  organ  which  is  ordinarily  readily  accessible 
is  found,  when  the  abdomen  is  opened,  to  be  firmly  bound  down, 
general  anesthesia  should  be  resorted  to  at  once  before  an  attempt 
is  made  to  loosen  the  adhesions.  Such  an  attempt  would  have 
no  other  effect  than  to  hurt  the  patient  and  destroy  his  equa- 
nimity. Similarly,  if  an  abscess  is  adherent,  it  can  easily  be 
drained ;  but  if  the  free  peritoneal  cavity  must  be  traversed  gen- 
eral anesthesia  is  indicated.  Introduction  of  a  protective  tam- 
ponade  under  local  anesthesia  should  not  be  attempted.  Nitrous 
oxide  can  be  easily  and  quickly  administered  and  serves  per- 
fectly in  most  cases.  If  a  more  protracted  operation  is  required, 
or  if  a  greater  laxity  of  the  abdominal  muscles  is  demanded  than 
can  be  secured  by  gas,  the  switching  to  ether  in  the  hands  of  a 
skillful  anesthetist  is  a  matter  of  but  a  few  minutes. 

NEURAL  ANATOMY  OF  THE  ABDOMINAL  WALL  AND  THE  CONTAIN- 
ED ORGANS. — The  abdominal  parietes  receive  branches  from  the 
seventh  to  the  twelfth  intercostal  nerves  and  from  the  ilio-ingui- 
nal  and  ilio-hypogastrics.  The  thoracic  nerves  after  leaving  the 
spinal  canal  pass  to  the  posterior  surface  of  the  intercostal  mem- 
brane, which  they  pierce,  and  in  company  with  the  intercostal 
vessels,  pass  forward  between  the  intercostal  muscles  (Fig.  70). 
The  ilio-inguinal  and  ilio-hypogastrics  are  concerned  chiefly  in 
the  operations  for  inguinal  hernia  and  are  described  in  that 
chapter. 

The  intercostal  nerves  reach  the  anterior  region  of  the  abdo- 
men by  passing  superficial  to  the  transversalis  muscle.  At  their 
midpoint  they  give  off  branches  which  supply  the  more  super- 
ficial structures,  including  the  skin  and  external  oblique  muscle 
at  the  lateral  surface  of  the  abdomen.  Other  branches  are  given 
off  at  the  border  of  the  rectus  which  supply  the  superficial  struc- 
tures of  the  anterior  surface  of  the  abdomen. 

Branches  are  given  off  near  the  semilunar  line,   which  per- 


Surgical  Operations  with  Local  Anesthesia  165 

forate  the  transversalis  muscle  or  run  in  its  substance  and  form 
a  plexus  superficial  to  the  peritoneum.  In  this  manner  the  peri- 
toneum receives  branches  from  the  lower  six  thoracic  nerves 
and  from  the  ilio-inguinal  and  the  ilio-hypogastric. 

The  plexuses  are  formed  by  the  reunion  of  branches  of  the 
same  or  neighboring  nerves.  Branches  are  given  off  from  these 
loops  which  supply  the  muscle  itself.  It  is  from  these  loops,  too, 
that  branches  are  given  off  to  supply  the  peritoneum.  Some  of 
these  nerves  pierce  the  fascia  at  once,  while  others  run  for  some 
distance  to  reach  the  semilunar  line  and  perforate  the  fascia  at 
or  near  this  line  to  reach  the  peritoneum. 

Within  the  preperitoneal  tissue  these  nerves  undergo  renewed 
plexus  formation,  and  branches  from  this  plexus  may  assume 
a  recurrent  direction  so  that  they  may  reach  a  point  near  their 
primary  origin  from  the  intercostal  before  breaking  up  into  their 
endorgans.  On  the  whole,  however,  the  general  direction  of  the 
terminal  branches  is  toward  the  median  line.  In  harmony  with 
the  developmental  change  of  position  of  the  abdominal  muscles 
the  terminal  filaments  are  directed  upward.  This  upper  tendency 
of  the  terminal  filaments  is  emphasized  by  the  hypogastric  branch 
of  the  ilio-hypogastric. 

It  is  important  to  note  relative  to  nerve  blocking  at  the  point 
of  origin  of  these  nerves  that  while  in  general  the  nerves  supply 
the  region  of  their  respective  muscle  segments,  because  of  the 
free  anastomosis  and  general  upward  direction  of  the  terminal 
branches  the  nerves  in  the  segments  below  likewise  require 
blocking. 

Ranstrom  has  studied  particularly  the  relation  of  the  inter- 
costal nerves  to  the  diaphragm  and  of  the  phrenic  to  the  peri- 
toneum. He  denies  the  correctness  of  the  teaching  that  the  dia- 
phragm receives  motor  fibers  from  the  intercostals  and  con- 
versely that  the  peritoneum  receives  sensory  fibers  from  the 
phrenic.  Numerous  dissections  of  my  own  cause  me  to  accept 
with  confidence  these  conclusions  of  Ranstrom. 

It  is  beyond  the  purpose  of  these  paragraphs  to  enter  minutely 


i66  Surgical  Operations  with  Local  Anesthesia 

into  the  study  of  the  termination  of  the  endorgans  into  the  peri- 
toneum. It  is  worth  noting,  however,  that  the  terminal  fibers  give  < 
off  from  the  plexuses  above  mentioned  are  for  the  most  part 
non-medullated  with  an  intermixture  of  a  small  number  of  vari- 
ously sized  medullated  fibres.  These  latter  divide  at  the  nodes  of 
Ranvier  in  such  manner  that  in  most  terminal  meshes  medullated 
fibres  are  found.  The  non-medullated  fibres  terminate  in  plexuses 
about  the  vessels,  showing  here  and  there  sympathetic  nerve  cells 
singly  or  in  groups,  while  the  medullated  terminate  in  the  sub- 
serous  and  serous  layer  in  special  endorgans.  These  endorgans, 
it  is  sufficient  to  note,  do  not  differ  from  the  Vater-Pacini  bodies 
found  in  other  regions  of  the  body. 

The  neural  anatomy  of  the  viscera  is  much  less  satisfactorily 
worked  out.  Auerbach's  plexus,  situated  between  the  muscle 
layers  of  the  intestine,  and  a  finer  one,  Meissner's,  situated  in  the 
submucosa,  are  well  known.  These  form  a  complete  web  about 
the  gut  and  from  them  filaments  have  been  traced  to  the  mucosa. 
Nerves  have  not  been  demonstrated  in  the  peritoneal  or  sub- 
peritoneal  layer. 

Sympathetic  nerves  have  been  traced  into  the  solid  viscera, 
but  of  their  ramification  within  them  little  is  known.  The  pres- 
ence of  medullated  fibers  within  the  visceral  plexuses  is  pure 
hypothecation. 

Much  discussion  has  arisen  relative  to  the  sensitiveness  of 
the  organs  involved  in  abdominal  operations.  Much  discussion 
has  been  due  to  a  disregard  of  the  anatomy  of  the  region  in 
question  and  still  more  to  an  attempt  to  transfer  data,  always 
necessarily  unreliable,  derived  from  animal  experimentation.  The 
abdominal  surgeon  can  use  only  real  facts.  The  patient,  and  not 
the  scientist,  sits  as  the  judge  of  trie  correctness  of  his  deduction. 

Broadly  speaking,  it  may  be  stated  that  pain  is  caused  when- 
ever a  sensory  nerve  is  exposed  to  experiences  of  an  irritating 
character  to  which  it  is  not  accustomed.  To  this  may  be  added 
that  the  stimuli  which  excite  pain  must  be  in  the  direction  of  an 
exaggeration  of  their  physiological  function. 


Surgical  Operations  with  Local  Anesthesia  167 

The  parietal  peritoneum  is  not  separable  in  surgical  practice 
from  the  transversalis  fascia,  and  for  practical  purposes  it  is 
convenient  to  regard  the  fascia  and  parietal  peritoneum  as  one 
structure. 

The  parietal  peritoneum,  as  above  noted,  contains  medullated 
fibers.  This  need  not  occasion  surprise  when  it  is  remembered 
that  the  prime  function  of  the  parieties  is  to  protect  the  viscera 
within  from  external  violence.  The  parietal  peritoneum  is  much 
less  sensitive  than  the  skin,  but  is  sensitive  to  section  or  stretch- 
ing because  none  of  these  manipulations  can  be  carried  out  with- 
out involving  endorgans  or  involving  the  nerves  in  continuity. 

The  response  elicited  from  a  nerve  injured  in  continuity  de- 
pends upon  the  degree  of  trauma  inflicted.  It  is  possible  to  pierce 
nerve  sheaths  with  a  fine  needle  without  pain,  while  a  large  or 
rusty  needle  excites  pain.  Even  a  relatively  large  needle  may  be 
thrust  into  the  sciatic  nerve  or  brachial  plexus  without  the  pro- 
duction of  noteworthy  pain.  In  picking  up  and  deliberately  irri- 
tating exposed  nerves,  pain  is  caused,  no  matter  where  the 
nerve  is  located.  If  fatty  tissue  is  picked  up  with  it,  as  usually 
is  the  case  in  manipulations  of  the  peritoneum,  less  pain  is 
caused  than  if  the  bare  nerve  is  grasped. 

The  parietal  peritoneum,  therefore,  like  any  other  tissue  bear- 
ing medullated  nerve  fibres  and  endorgans,  is  sensitive  to  trauma 
of  such  character  as  excites  pain  in  other  regions  supplied  by 
similar  nerve  structures,  the  differences  being  dependent  upon 
the  projection  of  the  surrounding  tissue  and  the  degree  of 
injury. 

It  is  necessary  to  treat  the  peritoneum  just  as  one  would  treat 
the  skin  if  one  were  working  from  within  the  abdomen  outward 
toward  the  skin.  In  other  words,  one  might  turn  his  patient 
wrong  side  out  and  not  alter  the  fundamental  problems  in  technic. 

The  visceral  peritoneum  does  not  contain,  so  far  as  is  known, 
any  medullated  nerve  fibers.  It  is  safe  to  conclude,  therefore, 
that  either  sympathetic  nerves  can  bear  painful  stimuli  or  there 
are  medullated  fibres  in  the  abdominal  viscera,  for  pain  may  be 


i68  Surgical  Operations  with  Local  Anesthesia 

experienced  when  these  nerves  are  irritated,  as  every  small  boy 
learns  during  the  green  apple  season. 

The  abdominal  viscera  are  sensitive  to  trauma  only  when 
such  trauma  produces  an  exaggeration  of  their  normal  function 
or  threatens  the  integrity  of  the  nerve.  Because  of  the  width 
.of  the  meshes  of  the  intestinal  plexus,  needles  of  considerable 
size  may  be  thrust  into  the  wall  without  disturbing  the  nerves, 
or  at  most  but  pushes  them  aside.  Light  pinching  does  not  cause 
pain,  because  the  nerves  are  well  padded  by  surrounding  tissue. 
Severe  pinching  which  crushes  the  organ  is  painful.  Clamping 
the  appendix  or  catching  the  gall  bladder  with  forceps  in  order 
to  draw  it  forward  is  painful.  Grasping  the  stomach  preliminary 
to  a  gastrostomy  is  painful.  That  traction  on  viscera  is  painful 
is  attested  to  by  all  operators.  This  is  due  largely  perhaps  to  the 
stretching  of  the  nerves  in  the  mesentery. 

Why  crushing  and  stretching  is  painful  while  cutting  is  little 
or  not  at  all  painful  is  open  to  speculation.  Colicky  pains  likely 
are  due  to  an  undue  sudden  stretching  of  the  contained  nerves. 
Cutting,  if  it  strikes  no  endorgans,  gives  no  pain.  In  opening  a 
gall  bladder,  for  instance,  if  its  summit  is  caught  up  by  two 
clamps,  pain  is  felt  when  each  f creep  is  tightened.  No  pain  is 
felt  when  the  top  of  the  viscus  is  cut  into.  If  now  the  operator 
attempts  to  enlarge  the  opening  by  dilatation,  severe  pain  is 
caused.  While  the  patient  does  not  complain  when  the  summit 
is  cut,  he  objects  to  the  use  of  the  stone  scoop  inside  and  the 
nearer  the  duct  the  more  the  complaint. 

The  diseased  peritoneum  suffers  quite  as  many  deviations 
from  the  normal  in  its  response  to  stimuli  as  it  does  in  anatomic 
structure.  A  dropsical  peritoneum  (having  been  infiltrated  by 
nature)  is  little  or  not  at  all  painful.  The  same  applies,  of 
course,  to  the  skin. 

Inflammation,  as  already  intimated,  influences  the  peritoneal 
sensibility  greatly  and  the  variation  seems  to  follow  the  same 
general  laws  that  govern  the  sensibility  of  the  somatic  system. 
Simple  hyperemia  does  not  increase  the  sensibility.  This  is  true 


Surgical  Operations  with  Local  Anesthesia  169 

whether  the  vascular  dilatation  is  caused  by  an  irritant  or  re- 
flexly. 

With  the  beginning  of  exudation,  sensation  is  much  heightened. 
This  applies  to  both  serous  and  cellular  exudates.  So  far  as 
my  studies  permit  me  to  judge,  that  stage  of  inflammation,  when 
the  connective  tissue  is  swollen  but  retains  its  specific  tinctorial 
reaction,  is  characterized  by  the  greatest  sensibility.  This  corre- 
sponds to  the  height  of  tissue  reaction  against  injury.  This  stage 
once  passed  sensation  lessens.  If  regression  begins  the  normal  is 
approached.  If  the  process  becomes  subacute  the  connective  tis- 
sue loses  its  specific  reaction  to  dyes  and  approaches  the  fibrin 
reaction.  Tissue  in  this  state  may  be  relatively  free  from  sen- 
sation. If  organization  begins  sensation  increases  and  may  equal 
or  exceed  that  of  acute  inflammation.  If  a  severely  toxic  pro- 
cess develops  sensation  may  be  lessened.  This  may  be  due  to  a 
soggy  edema.  No  effort  on  my  part  has  revealed  any  changes 
in  the  nerves  to  account  for  these  variations  in  sensibility  in 
the  various  stages  of  inflammation. 

In  order  to  give  concrete  form  to  these  observations,  I  may 
hypothecate  a  case  of  appendicitis  running  through  these  various 
stages.  In  the  acute  stage  the  appendix  and  immediately  adja- 
cent portion  of  the  cecum  is  inflamed  and  the  pain  is  heightened. 
Farther  up  the  ascending  colon  is  hyperemic,  clue  to  reflexes 
from  the  inflamed  area  and  is  not  abnormally  sensitive.  With 
the  increase  of  the  process  the  walls  of  the  appendix  become 
swollen'and  adhesions  are  formed.  This  stage  is  marked  by  ex- 
cessive sensitiveness.  If  this  stage  exists  for  some  time  the 
changes  in  the  tinctorial  reaction  above  noted  take  place  and 
sensitiveness  is  reduced.  Guts  in  this  stage  may  be  separated 
with  impunity.  If  restitution  begins  and  permanent  adhesions 
form,  the  tissues  become  more  sensitive  again.  The  pain  pro- 
duced by  carcinomatous  invasion  corresponds  to  this  stage  of 
the  reactive  process. 

These  data  here  tentatively  presented  were  gained  by  noting 
the  patient's  interpretation  of  the  sensitiveness  when  the  tissues 


170  Surgical  Operations  -with  Local  Anesthesia 

were  handled.  If  the  operation  was  productive  of  specimens 
these  were  religiously  examined  in  the  laboratory.  Similar  states 
were  produced  in  animals  and  these  studied.  Studies  of  nerve 
changes  in  these  conditions  were  fruitless.  I  regard  as  utterly 
useless  attempts  to  study  sensation  on  lower  animals.  An  inter- 
pretation of  the  gross  changes  in  the  viscera  above  noted  often 
gives  the  operator  the  clue  as  to  whether  or  riot  he  shall  call  for 
general  anesthesia.  These  studies,  I  am  aware,  have  been  but  a 
rattling  of  the  dry  brushes  of  the  valley,  while  the  timber-cov- 
ered mountains  lie  unexplored  before.  Nevertheless,  knowledge 
must  supplant  speculation  in  abdominal  anatomy  and  pathology 
before  we  can  discuss  intelligently  the  problems  of  local  anes- 
thesia. 

EXPLORATORY  OPERATIONS. — Not  infrequently  local  anesthesia 
finds  a  useful  application  in  exploratory  or  confirmatory  abdomi 
nal  section,  especially  in  cases  where  a  lesion,  usually  a  malig- 
nant tumor,  is  believed  to  be  inoperable,  yet  the  patient  demands 
the  benefit  of  the  doubt.  In  such  patients  an  exploration  under 
ether  is  an  operation  of  some  magnitude,  while  with  local  anes- 
thesia it  is  no  more  than  an  inconvenience.  Should  an  operable 
lesion  be  discovered  its  removal  may  be  undertaken  at  once 
under  local  or  a  general  anesthetic  may  be  administered.  If, 
for  instance,  an  operable  pyloric  tumor  is  present  a  gastro-enter- 
ostomy  may  be  done  under  local  if  the  patient's  condition  de- 
mands it,  and  the  removal  of  the  tumor  may  be  undertaken  at 
a  later  date.  Not  infrequently  it  is  difficult  to  distinguish  be- 
tween simple  stenosis  and  constriction  due  to  malignancy.  Local 
anesthesia  offers  a  simple  solution  of  the  problem  by  inspection 
and  gives  opportunity  for  establishing  permanent  drainage,  or, 
in  cases  where  the  tumor  is  operable,  for  a  complete  removal  of 
the  growth.  Dr.  E.  D.  Twyman  employs  local  anesthesia  in  prob- 
able gall-stone  cases.  He  proposes  to  the  patient  that  he  will 
make  an  inspection  under  local  anesthesia  and  if  no  gall-stones 
are  found  the  patient  will  be  spared  the  inconvenience  of  the 
general  anesthesia,  but  if  stones  are  present  a  general  anesthetic 


Surgical  Operations  with  Local  Anesthesia  171 

will  be  given  and  the  operation  completed.  Frequently  when  the 
gall  bladder  is  exposed  and  the  stones  demonstrated  it  is  possible 
to  complete  the  operation  under  local. 

Local  anesthesia  is  suitable  for  exploration  only  when  the 
surgeon  has  in  mind  a  definite  condition  to  exclude  or  confirm. 
When  he  has  only  a  vague  notion  of  some  abdominal  lesion,  local 
anesthesia  will  not  be  satisfactory,  because  it  does  not  give  op- 
portunity for  aimless  wanderng  about  in  the  abdominal  cavity. 

The  technic  of  an  exploratory  incision  does  not  differ  mate- 
rially from  that  of  any  other  incision.  If  the  operator  expects  the 
patient  to  remain  in  bed  for  a  day  or  two  only,  as  in  operations 
for  confirming  a  diagnosis,  the  incision  will  be  planned  in  posi- 
tion and  length  so  as  to  admit  of  the  firmest  immediate  closure 
of  the  wound.  Thus,  in  case  of  carcimoma  of  the  stomach  a 
short  incision  high  in  the  epigastrium  will  settle  the  question  of 
glandular  metastasis  and  operability  through  an  incision  that 
admits  at  most  two  fingers.  The  same  rule  applies  in  cases  of 
chronic  jaundice,  with  suspected  tumor  about  the  gall  ducts,  and 
over  the  sigmoid  or  pubes  in  malignancy  of  these  regions.  With 
a  short  incision  firmly  closed  the  patient  need  not  go  to  bed  at 
all.  Consequently  the  surgeon  gains  the  patient's  consent  for 
early  operation  and  the  patient  gains  the  surgeon's  consent  for 
late  exploration.  The  former  often,  and  the  latter  occasionally, 
results  in  vast  good  to  the  patient  and  much  satisfaction  to  the 
surgeon. 

Abdominal  exploration  under  local  anesthesia  will,  however, 
not  give  much  information  to  an  inexperienced  surgeon.  Many 
indeed  explore  the  cavity  under  ether  and  fail  to  clear  up  the 
diagnosis. 

The  method  of  infiltration  for  exploration  in  any  region  is 
the  same  as  that  for  typical  operations  and  will  be  discussed  in 
connection  with  the  respective  regions.  The  method  of  closure 
and  the  material  should  be  chosen  according  to  the  site  and  type 
of  incision  and  with  respect  to  the  condition  of  the  patient.  If 
the  condition  of  the  patient  is  such  that  he  should  not  be  in  bed 


172 


Surgical  Operations  zvith  Local  Anesthesia 


long,  the  wound  must  be  securely  sutured.  When  the  patient  is 
to  be  allowed  to  be  up  at  once  the  wound  should  be  sutured  with 
chromic  gut.  If  in  addition  the  patient  offers  conditions  which 


Fig.  71.     Elliptic  infiltration  of  the  abdominal  wall. 

make  a  disturbed  wound-healing  probable,  as  in  diabetes  or  jaun- 
dice, figure-of-8  silkwormgut  sutures  in  addition  to  the  catgut 
sutures  furnish  additional  security. 

THE  ABDOMINAL  INCISION. — General  rules  apply  to  the  infiltra- 
tion of  all  abdominal  incisions.     Two  methods  have  been  em- 


Surgical  Operations  with  Local  Anesthesia 


173 


ployed  in  anesthetizing  the  skin.  In  one  the  skin  is  infiltrated 
in  the  line  in  which  the  incision  is  to  be  made,  and  the  deeper 
parts  are  then  anesthetized  through  this  line.  In  the  other,  an 
ellipse  or  a  rhomboid  or  some  other  geometric  figure  is  described 
about  the  line  of  proposed  incision  (Fig  71).  By  this  method  the 
skin  contained  within  the  figure  is  anesthetized  and  may  be  in- 


Fig.  72.     Infiltration  of  the  abdominal  wall. 

cised  in  any  part.  My  preference  is  emphatically  in  favor  of  the 
former,  for  the  reason  that  a  single  prick  in  sensitive  skin  suf- 
fices, the  subsequent  injections  beginning  at  points  which  are 
already  anesthetized.  The  deeper  parts  can  be  reached  by  pass- 
ing the  needle  directly  downward  through  the  linear  infiltration 
(Fig.  72).  The  trained  operator  is  thus  enabled  to  anesthetize 
the  muscular  layer  and  the  transversalis  fascia  and  with  it  the 
peritoneum  before  the  skin  incision  is  made.  Meanwhile  the 
skin  has  lost  its  sensation  and  while  the  incision  is  made  and 
hemostasis  secured  the  deep  infiltration  is  becoming  effective. 


174  Surgical  Operations  with  Local  Anesthesia 

By  this  plan  it  is  unnecessary  that  the  operator  wait  for  the 
action  of  the  anesthetic  in  any  part  of  the  operation.  What  is 
of  even  greater  importance  in  extensive  operations  is  that  the 
linear  skin  infiltration  requires  much  less  anesthetic  solution. 

The  rhombic  method  not  only  requires  multiple  points  of  pri- 
mary infiltration,  each  of  which  adds  to  the  discomfort  of  the 
patient,  but  also  necessitates  the  use  of  several  times  as  much 
fluid  to  produce  anesthesia  of  the  skin.  If  it  is  desired  to  inject 
a  definite  line  in  the  deeper  tissues,  the  rhombic  figure  on  the 
skin  from  which  the  injection  is  made  prevents  any  great  accu- 
racy, and  the  amount  of  fluid  used  is  likely  to  be  excessive. 
The  single  advantage  of  the  method  is  that  the  operator  is  per- 
mitted to  handle  the  tissue  more  roughly.  Those  who  are  accus- 
tomed to  handle  all  tissues  with  the  greatest  delicacy  whether 
obliged  to  do  so  or  not,  will  not  regard  this  as  an  advantage. 
In  outlining  the  figure  on  the  skin  it  is  necessary  to  reach  all 
nerves  supplying  the  skin  within  its  confines.  If  nerves  reach  the 
area  from  a  depth  greater  than  that  to  which  the  infiltration  has 
reached  anesthesia  will  of  course  be  incomplete.  The  rhomboid 
method  is  unavoidable  for  lesions  which  must  be  circumscribed, 
such  as  post-operative,  and  umbilical  hernias,  and  tumors  which 
are  large  or  extensively  adherent. 

Sometimes,  particularly  in  fat  subjects,  when  it  is  not  possible 
to  infiltrate  the  muscle  and  fascial  plains  before  the  skin  is  in- 
cised, these  structures  must  be  injected  after  the  incision  is  made 
through  the  skin  and  fat.  The  inexperienced  will  find  a  resort 
to  this  method  necessary  in  most  cases.  The  reticular  tissue 
immediately  overlying  the  fascia  should  not  be  disturbed  before 
the  latter  is  infiltrated,  because  it  contains  nerve  filaments  and 
will  give  pain. 

The  fat  layer  as  a  rule  is  not  sensitive,  but  the  heavy  fascial 
bands  which  sometimes  traverse  it  often  contain  nerves.  The 
operator  can  often  divide  the  tissue  parallel  with  these  bands  and 
by  pushing  them  aside  avoid  even  the  slight  sensation  their  divi- 
sion causes.  Only  in  certain  areas,  to  be  mentioned  specifically 


Surgical  Operations  with  Local  Anesthesia  175 

later,  is  the  infiltration  of  fatty  layers  to  be  undertaken.  It  is  to 
be  avoided,  if  possible,  because  fat  at  best  heals  badly  and  the  ad- 
dition of  anesthetic  fluid  places  an  additional  burden  upon  the  re- 
parative  process,  and  because  the  increased  amount  of  anesthetic 
fluid  may  be  a  factor  of  importance  in  extensive  operations. 

PREPARATION  OF  THE  PATIENT. — Usually,  when  the  surgeon  sac- 
rifices the  convenience  of  general  anesthesia  in  abdominal  opera- 
tions, the  condition  of  the  patient  is  such  as  to  demand  special 
thought  as  to  preliminary  treatment.  For  operations  which  are 
done  by  choice  under  local,  especially  upon  the  abdominal  wall 
only,  the  ordinary  routine  of  preparation  is  sufficient.  For  emer- 
gencies, such  as  may  arise  in  intestinal  obstruction,  where  enteros- 
tomy  alone  is  indicated,  special  preparation  is  neither  conveni- 
ent nor  necessary.  Sterilization  of  the  skin  with  iodine  usually 
constitutes  the  preparation,  the  preliminary  injection  of  mor- 
phine not  being  generally  needed.  Careful  preparation  is  desir- 
able before  exploratory  operations  for  chronic  conditions,  espe- 
cially malignant  disease.  To  secure  the  best  cleansing  of  the 
digestive  tract  dependence  is  to  be  placed  upon  a  reasonable  diet 
and  simple  laxatives  and  enemas  rather  than  upon  starvation  and 
purges.  The  patient  should  be  kept  upon  a  diet  suited  to  his  con- 
dition up  to  the  very  time  of  entering  the  operating  room.  By 
careful  attention  to  this  detail  his  power  to  withstand  an  opera- 
tion can  be  materially  augmented,  and  the  abdominal  contents 
can  be  placed  in  a  much  more  favorable  condition  to  tolerate  the 
necessary  manipulations.  Patients  with  advanced  pulmonary 
disease  should  have  heroin  or  codein  in  order  to  prevent  cough- 
ing during  the  operation.  The  dietetic  preparation  of  patients 
with  diabetes  or  nephritis  should  be  carried  out  for  as  long  a 
period  as  possible  before  the  operation.  In  diabetes  the  use  of 
codein  for  several  days  before  the  operation  often  improves  the 
patient's  condition  with  astonishing  rapidity. 

GASTROSTOMY. — As  a  rule,  this  operation  is  required  for  car- 
cinoma of  thr  esophagus,  and  is  usually  performed  when  the 
stomach  can  r.  ,  -ger  be  entered  by  sounds  or  tubes.  Reliable 


176  Surgical  Operations  with  Local  Anesthesia 

evidence  as  to  the  size  and  position  of  the  stomach  is  difficult  to 
secure,  but  it  may  be  assumed  that  in  such  a  condition  the  stomach 
is  much  contracted.  An  operation  should,  therefore,  be  selected 
which  may  be  performed  with  the  least  possible  traction  upon  the 
stomach. 

A  line  four  inches  in  length  is  infiltrated  over  the  middle  of 
the  left  rectus  muscle  beginning  an  inch  or  two  below  the  costal 
margin.  The  deeper  parts  are  freely  infiltrated  through  the  un- 
opened skin.  Before  the  fascia  is  incised  the  transversalis  fascia 
should  be  infiltrated  for  an  inch  or  more  on  each  side,  so  that  the 
stomach  may  subsequently  be  attached  to  it  without  pain.  The 
incision  in  the  abdominal  wall  should  be  long  enough  to  allow 
the  stomach  to  be  distinguished  from  the  colon  by  inspection. 

Witzel's  or  Senn's  operation  is  the  preferable  one  when  the 
stomach  is  much  contracted.  When  it  is  not  contracted  any 
operation  desired  may  be  selected.  The  stomach  is  not  sensitive 
to  suturing,  but  is  very  sensitive  to  the  traction  of  the  sutures 
Therefore,  when  it  has  been  fixed  by  forceps  or  by  the  fingers 
of  the  assistant  the  wall  should  be  gently  infiltrated  with  quinine 
solution.  Care  should  be  taken  that  the  infiltration  be  not  too 
intense  or  it  will  interfere  with  plication  of  the  stomach  walls, 
and  will  cause  annoying  contractions  of  the  stomach  after  the 
operation  has  been  completed.  The  operation  is  finished  in  the 
usual  way. 

An  elliptical  infiltration  of  the  skin  with  a  corresponding  in- 
jection of  the  deeper  parts  offers  certain  advantages.  It  allows  a 
wider  range  of  operative  choice  and  is  especially  adapted  to  thin 
abdomens  where  a  proper  fascial  infiltration  can  be  made  through 
the  unopened  skin.  It  is  the  method  of  choice  when  Frank's 
operation  is  to  be  done. 

GASTROENTEROSTOMY. — The  preliminary  blocking  may  be  made 
either  as  an  'ellipse  or  in  a  straight  line.  The  important  thing  is 
to  have  the  incision  of  sufficient  length  and  far  enough  down  in 
relation  to  the  inferior  border  of  the  stomach  in  order  that  trac- 
tion upon  the  viscera  may  be  reduced  to  a  minimum.  Inasmuch 


Surgical  Operations  with  Local  Anesthesia  177 

as  the  operation  is  usually  done  for  pyloric  obstruction,  the 
lower  border  of  the  stomach  must  be  previously  determined 
either  by  insufflation  or  better  by  the  x-rays. 

The  line  of  infiltration  in  the  skin  should  be  six  inches  long, 
so  that  the  incision  in  the  fascia  may  be  at  least  five  inches  long. 
A  longer  incison  is  required  than  when  opening  under  ether  in 
order  that  the  jejunum  can  be  located  and  coapted  to  the  stomach 
without  too  much  tugging.  This  is  the  most  important  point  in 
the  planning  of  the  operation.  When  the  operation  is  done  for 
inoperable  carcinoma  of  the  pylorus  the  posterior  operation 
should  not  be  attempted,  because  tugging  on  the  stomach  is  par- 
ticularly likely  to  be  painful  on  account  of  the  infiltration  of  the 
wTalls.  The  stomach  is  also  often  unnaturally  fixed.  Since  the 
operation  is  at  best  but  palliative,  ultimate  results  are  of  less 
importance  than  in  cases  of  benign  stenosis.  The  anterior  opera- 
tion is,  therefore,  the  method  of  choice.  In  cases  of  benign  sten- 
osis the  posterior  operation  is  indicated  and  is  likely  to  be  easily 
carried  out,  particularly  if  considerable  dilatation  is  present. 

If  a  cholecystectomy  is  to  be  undertaken  under  local  anes- 
thesia, it  is  necessary  to  make  an  infiltration  between  the  gall- 
bladder and  liver.  This  is  best  begun  where  the  peritoneum 
deflects  from  the  liver  over  to  the  gall-bladder.  The  tissues 
about  the  cystic  duct  are  easily  infiltrated  by  passing  the  needle 
beneath  the  peritoneum,  parallel  with  the  duct,  and  a  cc.  of 
fluid  injected. 

In  either  operation  the  use  of  clamps  depends  upon  whether 
or  not  the  parts  can  be  brought  upon  the  surface  of  the  abdomen. 
If  the  operator  is  compelled  to  work  in  a  measure  within  the 
abdominal  wound,  long  clamps  may  exert  a  continuous  tugging. 
In  such  cases,  short  clamps  like  the  Bartlett  clamp  may  be  used 
with  advantage.  They  can  be  used  in  any  position  and  are  pre- 
ferable to  the  fingers  of  an  assistant. 

Feeding  may  begin  soon  after  the  operation  in  most  cases,  be- 
cause there  is  little  or  no  tendency  to  vomit.  This  is  often  a  mat- 
ter of  importance  in  patients  who  are  much  reduced  by  starvation. 


178  Surgical  Operations  with  Local  Anesthesia 

COLOSTOMY. — Permanent  drainage  of  the  colon  in  the  region 
of  either  the  cecum  or  the  sigmoid  is  frequently  best  performed 
under  local  anesthesia.  It  may  be  a  palliative  operation  or  pre- 


Fig    73.     Linear  infiltration  with  secondary  deep  infiltration  lines  for 
the  incision  for  acute  appendicitis. 

liminary  to  operative  removal  of  a  tumor.  Because  of  the  per- 
manency of  the  wound  the  best  method  is  to  describe  an  ellipse 
with  quinine  about  the  region  to  be  operated  upon  and  to  infil- 


Surgical  Operations  with  Local  Anesthesia  179 

trate  the  muscle  layers  freely  with  novocain-epinephrin.  The 
operation  requires  cutting  across  massive  bundles  of  muscle, 
which  are  more  or  less  richly  supplied  with  blood  vessels.  The 
thorough  infiltration  by  novocain-epinephrin  gives  a  relatively 
bloodless  field  and  permits  the  retraction  required  to  secure  the 
gut.  The  length  of  the  incision  should  be  from  three  to  five 
inches,  depending  on  whether  or  not  it  is  desirable  to  explore  th.' 
abdomen  in  order  to  find  out  if  the  lesion  causing  the  obstruction 
is  operable.  The  segment  to  be  drained  is  brought  into  the  wound 
and  held  by  a  row  of  sutures  surrounding  the  proposed  opening 
If  the  gut  conies  well  into  the  wound  it  can  be  retained  by  passing 
a  glass  rod  beneath  it.  If  the  indications  are  not  urgent  the  gut 
should  be  exposed  for  from  24  to  72  hours  before  it  is  opened. 

APPENDECTOMY. — Either  rhomboidal  or  lineal  infiltration  (Fig. 
73)  of  the  skin  can  be  made,  followed  by  massive  infiltration  into 
the  muscle.  The  muscle  injections  block  the  nerves  effectually 
and  permit  considerable  manipulation  of  the  tissues  medial  to 
them.  One-half  per  cent,  novocain-epinephrin  is  the  preferable 
solution.  It  is  better  to  make  the  incision  lateral  to  the  semilunar 
line  so  as  to  avoid  the  network  of  nerves  near  this  line.  Other- 
wise  some  of  the  nerve  fibers,  which  may  have  escaped  the  area 
of  infiltration  will  cause  pain  if  cut. 

The  ease  with  which  the  appendix  can  be  removed  depends 
upon  the  location  and  mobility  of  the  cecum.  When  this  can  be 
brought  into  the  wound  but  little  difficulty  will  be  experienced 
in  the  operation,  but  when  the  cecum  is  fixed  by  inflammatory 
adhesions  the  operation  may  be  by  no  means  easy.  Difficulty  is 
particularly  likely  to  arise  in  the  period  of  subacute  inflammation 
3  to  6  weeks  after  the  acute  attack.  It  is  this  uncertainty  as  to 
the  local  conditions  which  contraindicates  the  use  of  local  Anes- 
thesia in  all  cases.  Fortunately,  however,  these  patients  are 
usually  in  good  condition  and  the  operation  is  short,  so  that  gen- 
eral anesthesia  is  not  objectionable. 

In  acute  suppurative  lesions  where  the  abscess  is  well  walled 
off,  I  have  many  times  slid  the  patient  to  the  edge  of  his  bed,  in- 


180  Surgical  Operations  with  Local  Anesthesia 

filtrated  the  abdominal  wall  as  described,  opened  the  abscess, 
introduced  the  tube,  and  allowed  the  appendix  to  remain  for  a 
second  operation.  There  are  many  situations,  I  am  sure,  where 
patients  would  be  better  off  if  so  managed  rather  than  transported 
to  more  favorable  conditions.  All  that  is  essential  for  this  opera- 
tion is  a  good  syringe  and  a  diagnosis. 

GALL  BLADDER  DRAINAGE. — When  the  gall  bladder  is  long 
enough  to  reach  the  parietal  peritoneum,  drainage  can  easily  be 
secured  under  local.  A  line  in  the  skin  and  deep  layers,  three 
inches  long,  parallel  to  the  costal  border  and  an  inch  below  it,  is 
infiltrated  and  incised.  The  gall  bladder  may  then  be  grasped 
and  pulled  out  into  the  wound  and  anchored  either  before  or 
after  a  drainage  tube  has  been  placed.  This  method  is  partic- 
ularly desirable  when  the  condition  of  the  patient  is  unfavorable 
and  when  the  gall  bladder  is  much  distended  and  can  be  pal- 
pated through  the  unopened  wall. 

When  the  gall  bladder  is  to  be  drained  for  stones,  or  when 
the  common  duct  or  pylorus  is  to  be  explored,  a  long  vertical  inci- 
sion is  preferable.  It  should  extend  from  the  costal  border  down- 
ward for  at  least  five  inches,  and  should  be  preceded  by  infiltra- 
tion of  the  skin  and  deeper  layers.  A  long  oblique  incision  par- 
allel to  the  costal  margin  and  below  it  gives  better  access  to  the 
gall  bladder  than  the  longitudinal  incision,  but  is  not  as  well 
suited  for  reaching  the  pylorus  and  does  not  permit  an  examina- 
tion of  the  appendix.  The  chief  objection,  however,  is  that  it 
cuts  the  nerves  which  supply  a  considerable  part  of  the  abdom- 
inal muscles. 

The  operation  does  not  differ  from  that  done  under  general 
anesthesia,  if  the  gall  bladder  is  long  enough  to  reach  the  inci- 
sion. If  traction  is  necessary  the  operator  has  the  choice  of  sup- 
plementing local  injections  by  inhalation  anesthesia,  or  draining 
the  gall  bladder  deep  in  the  abdomen  and  allowing  the  drainage 
tube  to  supply  the  distance  between  the  gall  bladder  and  abdom- 
inal wall.  The  chief  difficulty  in  this  plan  is  the  proper  protec- 
tion of  the  environment  while  the  stones  are  being  removed. 


Surgical  Operations  with  Local  Anesthesia  181 

Unless  strongly  contra-indicated  a  supplementary  general  anes- 
thetic will  be  preferable. 

Superficial  abscesses  about  the  gall  bladder  may  be  blocked  by 
infiltration,  through  an  incision  parallel  to  the  costal  border, 
which  also  permits  satisfactory  drainage.  If,  however,  as  is 
usually  the  case,  there  is  a  perforation  or  escape  of  infective  ma- 
terial nearer  the  base  of  the  gall  bladder,  dense  adhesions  form 
which  cannot  be  removed  without  great  pain.  In  general,  for  the 
present,  operations  upon  the  gall  bladder  are  not  to  be  encouraged 
under  local  anesthesia.  Careful  exploration  and  finished  opera- 
tions are  more  difficult  than  under  general  anesthesia,  and  gener- 
ally speaking,  operations  in  this  region  are  now  done  with  too 
little  care. 


CHAPTER  XIV 

OPERATIONS  FOR  UMBILICAL  HERNIAS,  HERNIAS  OF  THE  LINEA 
ALBA  AND  SCAR  HERNIAS 

UMBILICAL  HERNIAS. — This  affection  is  most  common  in  stout 
women  past  middle  life,  who  are  also  poor  subjects  for  general 
anesthesia.  The  following  operation  has  been  found  uniformly 
satisfactory  in  all  patients  for  hernias  of  any  type  or  size : 


Fig.  74.     Line  of  infiltration  about  an  umbilical  hernia. 

An  ellipse  is  infiltrated  about  the  hernia  at  such  a  distance 
from  the  sac  that  it  is  easily  accessible  (Fig.  74).  If  it  is  desira- 
ble at  the  same  time  to  excise  superfluous  fat,  the  ellipse  must  be 
correspondingly  larger.  1  have  in  this  way  resected  pieces  of  fae 
measuring  a  foot  in  one  diameter  and  eight  inches  in  the  other, 
with  a  thickness  of  four  inches.  The  fatty  layer  should  be  in- 
jected through  the  primary  line  of  infiltration  with  a  weak  solu- 

182 


Surgical  Operations  u'ith  Local  Anesthesia 


183 


tion  (say  *4  Per  cent.)  of  novocain-epinephrin  or  quinine.  The 
fatty  layer  is  not  very  painful  and  the  amount  of  fluid  injected 
should  be  small.  Even  without  injection  section  of  the  fat  is 
painful  only  when  large  fascial  septa  are  cut.  For  small  hernia, 
in  which  the  amount  of  anesthetic  required  is  not  great,  novocain- 
epinephrin  may  be  used  throughout  the  operation.  I  use  quinine 


Fig.  75.     Infiltration  of  the  layers  of  the  abdominal  wall  in  umbilical  hernia.     The  skin 
has  not  been  incised.     (Redrawn  from  Braun). 

for  the  skin  in  all  cases.  In  large  hernias  quinine  is  imperative, 
because  the  amount  of  fluid  necessary  exceeds  the  limit  of  safety 
of  novocain. 

If  the  operator  is  experienced  and  the  abdomen  not  too  fat, 
the  abdominal  walls  may  be  anesthetized  through  the  primary  line 
of  infiltration  before  the  skin  is  incised.  The  fascia  about  the  ring 
is  freely  infiltrated  (Fig.  75).  This  gives  complete  anesthesia.  If 
conditions  are  less  favorable,  the  following  plan  is  more  certain : 
the  skin  is  incised  through  the  primary  infiltration  line  and  the 
fascia  is  exposed,  as  shown  partly  accomplished  in  Fig  76.  The 
abdominal  wall  about  the  ring  is  then  infiltrated  (Fig.  76),  fluid 
being  injected  just  beneath  the  fascia,  into  the  muscle  and  partic- 


1 84 


Surgical  Operations  with  Local  Anesthesia 


ularly  just  above  the  transversalis  fascia.  The  distance  from  the 
ring  at  which  the  injections  should  be  made  depends  upon  the 
size  of  the  opening.  If  it  is  large,  or  if  extensive  overlapping 
of  the  edges  of  the  ring  will  be  required,  the  injection  should  be 
made  at  least  an  inch  from  the  margin.  If  the  opening  is  small, 
the  injection  should  be  made  close  to  the  ring  (Fig.  75.)  By  this 
injection  the  ring  is  effectually  anesthetized  for  all  future  manip- 
ulations. 


Fig.  76.     Infiltration  of  the  fascial  1 


The  sac  is  now  opened  and  adhesions  of  omentum  and  gut 
freed  from  the  ring  and  from  each  other.  Any  excess  of  omen- 
tum is  excised  and  the  cut  edges  carefully  inverted  to  prevent 
subsequent  adhesions. 

The  flaps  are  now  prepared  for  overlapping.  Any  degree  of 
imbrication  is  possible  and  there  is  no  rigidity  of  the  muscles  or 
increase  in  intra-abdominal  pressure  when  the  sutures  are  passed. 


Surgical  Operations  zvith  Local  Anesthesia  185 


f 
\    !  •         ft 


Fig.  77.     The  first  row  of  sutures  is  passed  and  one  of  them  is  tied. 


Fig.  78.     The  second  row  of  sutures  passed  through  the  edge  of  the  upper 
flap  and  into  the  fascia  of  the  recti  below  the  opening. 


186  Surgical  Operations  zvith  Local  Anesthesia 

The  usual  Mayo  technic  may  be  followed  (Figs.  77  and  78),  or 
the  overlapping  may  be  done  laterally.  The  epinephrin  gives  a 
bloodless  field,  which  makes  the  technic  easier,  but  all  raw  edges 
should  be  protected  by  suture  to  prevent  oozing.  The  fatty 
layer  is  not  sutured.  The  skin  is  closed  with  silkworm  gut,  which 
should  be  placed  close  to  the  cut  edge  so  that  the  needle  does  not 
pass  beyond  the  primary  line  of  infiltration.  It  is  well  to  allow 
the  patient  to  walk  back  to  the  bed,  for  it  gives  her  a  sense  of 
confidence  and  pride  and  lessens  the  labor  of  the  attendants. 

HERNIA  OF  THE  LINEA  ALBA. — These  small  hernias  nearly  al- 
ways occupy  the  mid-line  and  are  exposed  best  through  a  line 
infiltrated  directly  over  the  summit.  In  the  rare  cases  of  hernia 
of  the  linea  semilunaris,  the  line  of  infiltration  corresponds  to  the 
lateral  border  of  the  rectus.  It  is  well  to  make  the  primary 
infiltration  much  longer  than  the  apparent  need,  so  that  if  the 
hernia  has  a  long  pedicle,  which  is  not  uncommonly  the  case,  it 
will  not  be  necessary  to  make  a  second  infiltration  in  order  to 
reach  it. 

After  the  primary  line  has  been  infiltrated  the  external  fascia 
is  anesthetized  by  injecting  the  tissues  immediately  above  it. 
The  operator  readily  perceives  when  the  needle  touches  the 
fascia,  and  if  he  does  not,  the  patient  will  tell  him.  After  the 
prefascial  tissue  is  injected  the  needle  passes  through  the  fascia 
into  the  edge  of  the  rectus  muscle.  This  region  is  freely  infil- 
trated so  as  to  anesthetize  the  tissue  external  to  the  transversalis 
fascia.  The  entire  region  of  the  operation  is  then  anesthetic. 
If  the  operator  cannot  find  the  fascia,  the  skin  and  subcutaneous 
fat  may  be  incised  first,  and  the  fascia  and  deeper  layer  infiltra- 
ted when  exposed. 

Any  operation  desired  may  be  done.  As  suggested  above,  it 
is  well  to  make  a  fairly  long  incision  into  the  abdomen  so  that 
the  relations  of  the  pedicle  to  the  interior  of  the  abdomen  may  be 
determined. 

SCAR  HERNIAS. — A  bulging  scar  presents  much  the  same  prob- 
lem as  an  umbilical  hernia,  but  is  likely  to  be  more  complicated. 


Surgical  Operations  with  Local  Anesthesia  187 

Unless  the  operator  is  quite  sure  of  himself,  he  should  carefully 
consider  beforehand  the  nature  and  extent  of  these  complications. 

A  line  is  infiltrated  circumscribing  the  old  scar.  If  the  wall 
is  not  too  thick  the  fascial  and  muscle  layers  may  be  infiltrated 
through  the  primary  line.  At  any  rate  the  subcutaneous  fatty 
layer  should  be  infiltrated,  because  it  is  likely  to  contain  thickened 
fascial  bands  resulting  from  the  disturbed  healing  which  caused 
the  scar.  If  the  fascia  and  muscle  have  not  previously  been  in- 
filtrated, this  is  done  after  the  skin  and  subcutaneous  tissue 
have  been  incised.  It  is  well  to  make  this  infiltration  an  inch  or 
so  from  the  edge  of  the  bulging  scar,  because  there  are  cer- 
tainly adhesions  about  the  edge  of  the  hernia,  which  sometimes 
extend  a  considerable  distance,  and  unless  this  precaution  is  taken 
pain  will  be  caused  when  they  are  separated. 

From  this  point  the  problem  is  the  same  as  when  operating 
under  general  save  that  the  abdominal  wall  is  pale  and  flaccid 
from  the  novocain-epinephrin.  For  this  reason  the  operator 
must  use  more  than  ordinary  care  not  to  cut  an  adherent  intes- 
tine in  opening  the  abdomen. 

If,  when  the  opening  is  exposed,  it  is  found  too  large  to  allow 
direct  apposition,  a  flap  of  the  adjoining  fascia  must  be  loosened 
and  turned  over  the  defect.  Additional  infiltration  must  then 
be  made  in  the  area  from  which  the  flap  is  to  be  taken.  If  suffi- 
cient firmness  is  not  secured  by  this  means,  a  fascial  transplant 
may  be  secured  from  the  thigh  after  the  technic  of  Dr.  A.  T. 
Mann.  For  the  skin  infiltration  about  the  hernia  and  for  infil- 
trating the  thigh  for  a  transplant,  quinine  is  used.  For  the  tissue 
about  the  hernial  opening  novocain-epinephrin  is  preferable. 

In  the  repair  of  scar  hernias,  local  anesthesia  is  especially 
gratifying  to  the  patient,  who  has  usually  already  been  subjected 
to  anesthetization  by  ether,  and  is  in  a  position  to  know  what  he 
has  escaped  if  a  successful  operation  is  performed  under  local 
anesthesia. 


CHAPTER  XV 

OPERATIONS  ON  HERNIAS 

9 

Operations  for  hernia  have  been  done  under  local  anesthesia 
more  frequently  than  any  other  operation  of  like  magnitude. 
The  reason  for  this  is  that  this  operation  can  be  done  with  ease 


Fig.  79.     Nerve  supply  of  the  inguinal  region 

because  of  the  definite  anatomic  relations  of  the  structures  in- 
volved. The  patient  is  often  desirous  of  escaping  the  general 
anesthetic,  the  disadvantages  of  which  have  "been  unduly  magni- 

188 


Surgical  Operations  with  Local  Anesthesia  189 

fied  by  those  irregulars  who  pretend  to  produce  a  cure  by  non- 
operative  means.  Many  patients  indeed  have  refused  operation 
until  they  find  that  it  can  be  done  without  a  general  anesthetic. 
It  is  surprising,  too,  that  many  doctors  who  have  long  borne  the 
inconvenience  of  their  hernias  submit  readily  to  operation  when 
they  once  observe  the  efficiency  of  local  anesthesia.  While  the 
most  frequent  reason  for  employing  local  anesthesia  is  that  it 
causes  less  inconvenience  to  the  patient,  in  a  few  patients,  par- 
ticularly those  of  advanced  years,  operation  may  be  advised 
where  general  anesthesia  would  be  prohibitive. 

All  hernias  may  be  operated  under  local  anesthesia.  Simple 
inguinal  hernias  furnish  suitable  objects  for  the  introduction  of 
the  beginner  into  the  use  of  local  technic,  while  some  of  the  large 
scrotal  or  interstitial  ones  furnish  good  exercises  for  the 
experienced  technician.  It  becomes  necessary,  therefore,  for 
the  operator  to  measure  his  experience  with  the  particular  case 
before  him  if  he  is  to  avoid  perplexities  and  disappointment  for 
himself  and  pain  to  the  patient.  In  the  following  description  the 
operations  are  given  in  detail  in  order  that  the  junior  surgeon 
may  anticipate  the  possible  difficulties  at  the  various  stages. 

NEURAL  ANATOMY. — The  nerve  supply  in  the  region  of  in- 
guinal and  femoral  hernias  is  furnished  by  the  ilio-inguinal,  ilio- 
hypogastric,  and  genito-crural  nerves  (Fig.  79). 

THE  ILIO-INGUINAL  arises  f  rom  the  first  lumbar  nerve  and  passes 
across  the  quadratus  lumborum  muscle,  pierces  the  transversalis 
muscle  and,  associated  with  the  ilio-hypogastric,  follows  the  curve 
of  the  crest  of  the  ilium.  It  pierces  the  internal  oblique  muscle 
in  front  of  and  above  the  anterior  superior  spine  of  the  ilium 
and  reaches  the  inguinal  carfal  by  following  Poupart's  ligament 
under  cover  of  the  fascia  of  the  external  oblique.  In  the  canal 
it  lies  upon  the  cord  at  its  anterior  and  upper  surface  and  is  the 
first  object  to  come  into  view  when  the  canal  is  opened  (Fig.  84). 
It  escapes  the  canal  at  the  external  (medial)  ring  and  supplies 
the  skin  of  the  upper  inner  part  of  the  thigh  and  the  upper  part 
of  the  scrotum,  and  the  root  of  the  penis  in  the  male  and  the  ex- 


190  Surgical  Operations  with  Local  Anesthesia 

treme  upper  part  of  the  labium  majus  in  the  female.  It  usually 
lies  as  a  white  band  the  size  of  a  thick  darning  needle  upon  the 
hernial  sac.  Occasionally  it  divides  before  entering  the  canal 
and  is  then  spread  out  into  a  number  of  fine  filaments. 

ILIO-HYPOGASTRIC. — This  nerve,  like  the  preceding,  arises  from 
the  first  lumbar  nerve  and  passes  along  the  crest  of  the  ilium  in 
company  with  it.  Before  reaching  the  anterior  superior  spine  of 
the  ilium  it  divides  into  an  iliac  branch,  which  passes  over  the 
crest  of  the  ilium  and  is  of  no  interest  in  this  connection,  and  a 
hypogastric  branch  which  continues  in  company  with  the  ilio- 
inguinal.  At  or  near  the  anterior  superior  spine  it  parts  company 
with  its  companion  and  reaching  the  under  surface  of  the  fascia 
of  the  external  oblique,  passes  between  this  fascia  and  the  inter- 
nal oblique  muscle  to  a  point  about  an  inch  above  the  external 
(medial)  ring  where  it  pierces  the  fascia  and  is  distributed  to  the 
neighboring  skin. 

The  important  point  in  the  relation  of  these  two  nerves  is  that  at 
a  point  3  or  4  cm.  above  and  medial  to  the  anterior  superior  spine 
and  over  the  crest  of  the  ilium  beyond,  they  lie  close  together  and 
may  be  blocked  at  this  point  (Fig.  79)  by  an  anesthetic  solution. 

THE  GENITO-CRURAL. — This  nerve,  formed  by  the  union  of 
fibers  from  the  first  and  second  lumbar  nerves,  runs  on  the  sur- 
face of  the  psoas  muscle  under  cover  of  the  peritoneum  to  reach 
the  outer  side  of  the  external  iliac  artery.  Here  it  divides  into  a 
crural  branch,  which,  accompanying  the  iliac  vessels,  pierces 
the  facia  and  supplies  the  skin  about  the  saphenous  opening,  and 
a  genital  branch  which  accompanies  the  spermatic  vessels  through 
the  inguinal  canal  and  supplies  the  scrotal  contents  and  after 
piercing  the  spermatic  fascia  supplies  the  cremaster  muscle. 

In  many  instances  this  nerve  is  fused  with  the  ilio-inguinal. 
When  such  is  the  case  the  blocking  of  this  nerve  secures  anes- 
thesia of  all  the  scrotal  contents.  Frequently  the  nerve  divides 
into  numerous  filaments  which  are  distributed  to  the  cord.  In 
most  instances  the  vas  secures  fibers  high  up  in  the  canal  so  that 
if  the  cord  itself  is  to  be  attacked  the  whole  cord  must  be  blocked. 


Surgical  Operations  with  Local  Anesthesia  191 

In  addition  to  the  above-described  nerves,  branches  from  the 
pudic  and  small  sciatic  nerves  supply  the  posterior  surface  of 
the  root  of  the  scrotum.  The  upper  part  of  the  scrotum  is 
probably  supplied  by  nerves  from  the  sacral  plexus,  as  well  as 
by  the  nerves  above  described.  This  arrangement  of  the  nerves 
makes  it  necessary  in  large  scrotal  hernias,  particularly  in  those 
containing  strangulated  omentum,  to  block  the  skin  and  fascia 
about  the  root  of  the  scrotum  as  well  as  the  nerves  in  the  inguinal 
canal. 

Novocain-epinephrin  YZ%  is  the  most  convenient  solution  to 
use.  In  extensive  cases  /4%  may  be  used  for  the  deeper  struc- 
tures. In  very  large  hernias  this  may  be  supplemented  by  quinine 
solution,  or  the  latter  may  be  used  throughout. 

INGUINAL  HERNIA. — Either  of  two  plans  may  be  followed  in 
the  operation  for  the  radical  cure  of  inguinal  hernia.  I.  The 
operation  as  first  developed  by  Gushing  (Ann..  Surg.  1900, 
XXXI,  i),  consisted  in  the  successive  infiltration  and  division 
of  the  various  layers,  together  with  a  direct  injection  of  the  ilio- 
inguinal  nerve  after  it  was  exposed.  II.  Preliminary  wide  infil- 
tration of  the  field  of  operation,  thus  blocking  off  all  the  nerves 
before  the  operation  is  begun. 

The  first  operation  demands  a  more  exact  technic  and  requires 
much  less  anesthetic  fluid  than  the  plan  of  massive  injection. 
The  beginner  will  find  that  his  attempts  at  massive  injection 
will  often  fail  at  some  point,  and  it  is  of  importance  at  such  times 
to  know  just  how  to  supplement  it  by  secondary  injections.  For 
this  reason  the  operation  as  done  by  Gushing,  with  some  modifi- 
cation in  its  various  steps,  will  first  be  described,  followed  bv 
the  description  of  a  technic  more  convenient  to  the  experienced 
operator. 

INFILTRATION  BY  LAYERS. — The  skin  incision  should  be  plan- 
ned in  reference  to  convenience  in  operating  and  also  to  ease 
in  retaining  a  dressing  after  the  operation  has  been  completed. 
The  former  demand  is  met  by  an  incision  in  the  line  of  the  in- 
guinal canal  (Fig.  80),  and  the  latter  by  one  placed  higher  up  in  a 


192 


Surgical  Operations  with  Local  Anesthesia 


nearly  transverse  direction  (Fig.  81).    The  former  is  to  be  rec- 
ommended for  the  beginner. 

The  skin  is  infiltrated  in  the  line  of  the  inguinal  canal,  extend- 
ing from  the  root  of  the  penis  to  a  point  lateral  to  the  internal 


Fig.  80.     Line  of  infiltration  for  inguinal  hernia,     a,  Subcutaneous  infiltration  to  reach  the  nerve 

accompanying  the  superficial  inferior  epigastric  vessels;  b,  infiltration  superficial  to  the 

columns  of  the  external  ring  to  reach  nerve  twigs  from  the  ilio-hypogastric; 

c,  injection  in  the  root  of  the  scrotum  supplied  by  the  pudic 

and  small  sciatic  nerves. 

ring.  If  the  hernia  extends  into  the  scrotum  the  infilt.ation 
may  extend  downward  upon  the  scrotum.  This  increases  the 
ease  of  operation,  but  increases  the  liability  to  infection,  because 


Surgical  Operations  with  Local  Anesthesia 


193 


the  skin  of  the  root  of  the  scrotum  is  difficult  to  sterilize.     For 
this  reason  it  should  not  be  extended  farther  than  necessary. 

Usually  there  is  a  superficial  nerve  accompanying  the  super- 
ficial branches  of  the  deep  epigastric  vessels  and  an  injection  into 
the  subcutaneous  tissue  will  block  it  (a,  Fig.  80).  Likewise  over 
the  external  ring  branches  of  the  ilio-inguinal  and  the  ilio-hypo- 
gastric  reach  the  subcutaneous  tissue  and  may  be  blocked  by  in- 


Infernal nn<j    ;~^ 


Fig.  81.     High  skin  incision  for  inguinal  hernia. 

filtration  of  the  subcutaneous  tissue  at  this  point  (b,  Fig  80). 
In  cases  where  the  incision  must  be  extended  farther  down  on 
the  root  of  the  scrotum  a  third  point  (c,  Fig  80  )  may  be  infil- 
trated. 

The  incision  is  now  made  to  expose  the  superficial  deep  epigas- 
tric vessels  (Fig  82).  These  are  clamped,  cut  and  ligated.  If 
the  incision  extends  down  far  enough  to  reach  the  pudic  vessels 
these,  too,  must  be  identified  before  they  are  cut  and  clamped  and 


194  Surgical  Operations  with  Local  Anesthesia 


Fig    S'2.     Superficial  deep  epigastric  vessels. 


Fig.  83.     The  fascia  of  the  external  ring  is  exposed,     a.  point  nf  infiltration  about  the 

internal  (lateral)  ring;  b.  point  of  infiltration  about 

the  external  (median)  ring. 


Surgical  Operations  with  Local  Anesthesia 


195 


ligated.  This  care  is  necessary  in  order  to  keep  the  tissues  free 
from  blood  in  order  not  to  obscure  the  anatomic  structures. 
These  vessels  having  been  secured  the  subcutaneous  tissue  is 
divided  down  to  the  fascia  of  the  external  oblique  muscle. 

When  this  fascia  is  exposed,  the  pillars  (b,  Fig.  83),  and  the 
muscle  bundles  at  a  point  where  they  disappear  to  make  the  ex- 
ternal oblique  fascia  (a,  Fig.  83),  are  infiltrated.  The  infiltra- 
tion at  this  point  should  be  freely  made  so  as  to  reach  the 


Fig.  84.     The  fascia  of  the  external  oblique  is  incised  and  the  edges  are  caught  up  by  forceps  and 

retracted.     In  the  depths  of  the  wound  the  cord  and  sac  are  exposed  showing  the  nerve  at 

the  summit.       a,   Infiltration  of  the  ilio-inguinal  nerve  at  its  exit  from 

the  internal  canal;  b,  infiltration  of  the  muscle  necessary  only 

when  the  muscle  is  incised  to  permit  greater 

displacement  of  the  cord. 

cord  and  sac.  This  anesthetizes  the  area  of  the  ring  to  which 
the  sac  is  attached  and  prevents  pain  when  the  sac  is  ligated. 
The  remainder  of  the  fascia  is  not  sensitive  and  may  be  freely 
divided.  When  divided  it  is  well  to  pick  up  the  free  edges  and 
retain  them  with  forceps  in  order  that  they  may  be  readily 
identified  at  any  time  (Fig.  84). 


• 

196 


Surgical  Operations  with  Local  Anesthesia 


The  cord  and  sac  now  lie  in  the  bottom  of  the  wound.  If  the 
parts  have  been  kept  free  from  blood  the  ilio-inguinal  nerve  is 
now  seen  passing  over  the  center  to  disappear  down  into  the 
scrotum.  This  nerve  is  now  injected  directly  at  the  point  where 
it  emerges  through  the  internal  ring  (a,  Fig.  84).  This  injection 
is  made  more  readily  if  the  nerve  is  picked  up  with  suitable 
forceps  (Fig.  10).  The  sac,  lying  above  and  external  to  the  cord  ; 


Fig.  85.     The  cord  is  lifted  from  its  bed  with  forceps.     The  sac  shows  above,  and  be- 
low is  the  cord  including  the  vessels  and  fat.     a    Point  for  injecting 
the  cord;  6,  deep  epigastric  vessels. 


is  now  identified.  It  is  grasped  with  forceps  and  raised  up  (Fig. 
85).  This  carries  with  it  the  cord.  The  genital  branch  of  the 
genito-crural  nerve  is  now  blocked  by  injecting  the  cord  where 
it  emerges  from  the  ring  (a,  Fig.  85).  The  inferior  deep  epigas- 
tric vessels  are  seen  in  the  depth  of  the  wound  beneath  the  cord 
(b,  Fig.  85).  If  these  vessels  are  identified  they  are  not  likely  to 
be  injured  in  suturing. 


Surgical  Operations  with  Local  Anesthesia 


197 


The  sac  is  now  separated,  opened  and  ligated.  If  this  causes 
pain,  owing  to  previous  imperfect  injection,  the  sac  may  be  in- 
jected about  its  base  (Fig.  86).  This  is  rarely  necessary  unless 
there  are  adhesions  of  viscera  to  the  inside  of  the  sac. 

The  closure  of  the  wound  is  most  easily  accomplished  by  dis- 
placing the  cord  backward  and  uniting  the  conjoined  tendon  with 


Fig.  86.     The  sac  has  been  separated  from  the  cord  and  opened  to  admit  the  finger.     A 

threaded  needle  is  being  passed  eye  end  first  through  the  base  of  the  sac. 

The  dotted  line  shows  the  points  for  infiltrating  the  cord. 

Poupart's  ligament  in  front  of  the  cord  (Fig.  87)  or  the  typical 
Baccini  operation  may  be  done.  The  suture  of  the  fascia  of 
the  external  oblique  (Fig.  88)  and  skin  completes  the  operation. 
It  will  be  noted  that  the  above  directions  advise  the  repeated 
injection  of  the  same  region.  If  the  injection  at  Fig.  80,  or  a, 
Fig.  84,  is  properly  made,  the  cord  and  sac  will  be  completely 


198 


Surgical  Operations  with  Local  Anesthesia 


blocked.  In  that  event  the  separate  infiltration  of  the  nerve  a. 
Fig.  85,  will  not  be  needed.  The  same  is  true  of  the  sac.  But 
should  the  high  separation  of  the  sac  still  be  painful  after  the 
filtration  at  a,  Fig.  83,  has  been  made,  the  plan  shown  in  Fig. 
86  may  be  followed.  The  same  may  be  said  regarding  the  sep- 
arate infiltration  of  the  cord  at  a,  Fig.  85.  No  apology  is  offered 
for  presenting  these  details.  I  have  seen  operators  fail  for 
the  lack  of  knowledge  of  just  such  trifling  details. 


Fig.  87.     The  sutures  are  being  passed  through  the  conjoined  tendon  and   Poupart's 
ligament.     The  cord  is  behind  this  line  of  sutures. 

PRELIMINARY  NERVE  BLOCKING. — In  this  method  the  entire 
nerve  supply  is  blocked  at  the  point  where  they  lie  most  closely 
together,  namely  above  and  medially  to  the  anterior  spine 

(Fig-  79)- 

The  line  of  the  skin  is  first  infiltrated  (Fig.  89).  At  a  point 
medial  to  the  anterior  superior  spine  the  deep  infiltration  is  made. 
The  needle  is  passed  obliquely  upward  and  outward  (a,  Fig.  89). 
The  fascia  of  the  external  oblique  is  felt  as  a  definite  resistance 


Surgical  Operations  n.'ith  Local  Anesthesia  199 

to  the  needle.  Usually,  too,  the  patient  feels  a  slight  pain  when 
the  point  of  the  needle  passes  the  fascia.  If  the  operator  is  nor 
certain  of  the  position  of  his  needle  he  can  determine  the  position 
of  the  point  of  the  needle  by  moving  it  about.  If  the  point  is 
still  imbedded  in  the  fatty  layer  it  will  move  about  readily,  but 
after  it  has  passed  the  fascia  it  cannot  be  so  moved.  The  needle 
having  penetrated  the  fascia  is  passed  for  a  centimeter  or  two 


Fig.  88.     The  fascia  is  now  closed  with  interrupted  sutures   allowing  at  the 
lower  end  of  the  incision  for  the  passage  of  the  cord. 

along  the  muscle  and  the  anesthetic  solution  deposited.  By- 
passing the  needle  first  more  obliquely  upward  and  then  down- 
ward toward  the  spine,  all  the  nerves  in  this  region  are  sure  to  be 
reached. 

It  is  well  now  to  infiltrate  the  muscle  about  the  internal  ring  (b, 
Fig.  89  and  Fig.  90).  This  anesthetizes  the  attachment  of  the 
peritoneum  at  the  ring  and  makes  the  subsequent  high  separation 
and  ligation  of  the  sac  painless.  It  will  likewise  block  off  the 


2oo  Surgical  Operations  with  Local  Anesthesia 


}j   Internal  rintf 
\    -External  ••  •*** 


Fig.  89.     Nerve  blocking  for  inguinal  hernia.     <i,  Deep  infiltration  into  the  abdominal  muscles  to 

block  the  ilio-inguinal  and  ilio-hypogastric  nerves;  b.  infiltration  about  the  internal  ring 

to  anesthetize  the  attachments  of  the  sac;  c,  infiltration  about  the  pillars  to 

block  accessory  and  aberrant  nerve  filaments. 


Fig.  90.     Schematic  transverse  section  of  the  inguinal  canal.     Needles  correspond  to 

a,  b,  c,  Fig.  89,  reaching  the  ilio-inguinal  and  hypogastric  nerves,  the 

structures  about  the  internal  ring,  and  the  structures 

about  the  pillars  respectively. 


Surgical  Operations  with  Local  Anesthesia  201 

genito-crural  nerve  and  make  the  manipulations  of  the  cord  pain- 
less. Ordinarily  the  blocking  so  far  as  described  anesthetizes  the 
tissue  about  the  external  ring  as  well.  Sometimes,  however, 
this  region  receives  branches  from  the  twelfth  dorsal  and  from 
the  pudic.  In  order  to  make  sure  of  complete  anesthesia  it  is 
well  to  deposit  a  small  amount  of  the  fluid  above  and  below  the 
pillars  of  the  external  ring  (Fig.  90). 


Fig.  91.     The  sac  containing  the  strangulated  gut  is  exposed  and  the  constricting  ring 

is  identified  with  the  finger  and  is  being  cut  with  the  scissors.     The 

dotted  lines  show  the  lines  of  infiltration. 

The  time  required  for  making  this  infiltration  is  about  six  min- 
utes. In  order  for  anesthesia  to  be  complete  it  is  necessary  to 
wait  five  or  ten  minutes  longer.  Skin  anesthesia  is  already  com- 
plete, however,  and  if  the  operator  begins  at  once  and  carefully 
exposes  the  superficial  vessels  and  ligates  them,  by  the  time  the 
fascia  is  reached  the  blocking  will  be  complete  and  a  wait  on 
the  anesthesia  is  not  necessary. 


2O2  Surgical  Operations  with  Local  Anesthesia 

So  planned  the  time  consumed  is  no  greater  than  operating 
under  a  general  anesthetic.  A  moderately  skillful  operator 
should  turn  out  a  hernia  operation  every  30  or  40  minutes.  What 
little  time  is  lost  in  the  infiltration  is  made  up  by  the  expedition 
with  which  the  patient  gets  out  of  the  way.  He  walks  out  of  the 
operating  room,  thus  consuming  less  time  than  would  be  required 
to  haul  him  out  with  a  cart. 

So  injected  any  operation  desired  may  be  done  without  further 
thought  as  to  anesthesia.  If  through  inexperience  the  operator 
fails  to  secure  satisfactory  anesthesia  in  any  stage  of  the  opera- 
tion he  can  supplement  it  after  the  plan  first  described. 

Under  unusual  conditions  the  experienced  operator  may  be 
compelled  to  supplement  his  primary  infiltration.  In  very  fat 
patients  it  is  sometimes  difficult  to  reach  the  plane  of  the  nerves 
beneath  the  external  oblique,  because  the  distance  is  difficult  to 
estimate,  or  the  needle  available  may  be  too  short. 

In  persons  who  have  worn  a  truss  for  a  long  time  or  have  suf- 
fered many  strangulations,  the  connective  tissue  planes  may  be  so 
thickened  as  to  lead  the  operator  into  mistaking  them  for  the 
fascia  of  the  external  oblique,  and  in  consequence  he  deposits  the 
solution  above  instead  of  beneath  that  structure.  Sometimes,  too, 
in  these  persons  the  layer  of  fat  between  the  skin  and  fascia 
is  surprisingly  thin.  In  such  instances  the  needle  may  be  passed 
entirely  through  the  abdominal  wall  by  mistaking  the  transver- 
salis  for  the  external  oblique  fascia. 

In  lipomas  of  the  inguinal  canal  associated  with  hernia  failure 
to  secure  anesthesia  is  a  common  occurrence.  They  usually  have 
wide  attachments  in  the  preperitoneal  fat,  which  necessitates 
infiltration  through  the  abdominal  muscles  coextensive  with  the 
tumor.  If  the  extent  of  the  tumor  is  accurately  judged,  how- 
ever, anesthesia  can  readily  be  secured  before  the  skin  is  incised. 

With  nerve  blocking  as  above  described  hernial  sacs  of  any 
extent  can  be  dissected  out  with  ease.  If  the  sac  is  extensive  it 
may  be  allowed  to  remain,  precautions  against  hydrocele  being 
taken  by  means  of  obliterating  sutures. 


Surgical   Operations  with  Local  Anesthesia 


20- 


The  large  rhomboidal  infiltration,  as  advised  by  Braun,  obviates 
the  necessity  of  delicacy  in  manipulation  and  saves  time.  It  is 
satisfactory  in  plethoric  subjects,  but  in  nervous  patients  is  less 
likely  to  produce  satisfactory  results  than  the  more  delicate  pro- 
cedure above  recommended. 


Fig.  92.     Skin  infiltration  about  a  femoral  hernia,     a,  Point  of  entrance  for  infiltration 

about  the  neck  of  the  sac.     This  point  reaches  the  crural  branch  of  the 

genito-crural;  6,  point  for  infiltration  medial  to  the 

sac  reaching  the  pudic  nerves. 

STRANGULATED  INGUINAL  HERNIA. — In  cases  of  strangulation 
the  problems  depend  upon  the  degree  of  inflammatory  reaction 
present.  In  early  cases  the  operation  differs  in  no  wise  from 


204  Surgical   Operations  with  Local  Anesthesia 

operations  on  patients  in  which  strangulation  has  not  occurred, 
save  that  the  infiltration  is  made  about  the  inguinal  canal  and 
not  into  it  for  fear  of  puncturing  the  gut. 

In  cases  in  which  the  tissue  is  very  edematous  the  action  of 
the  anesthetic  is  interfered  with,  and  it  is  preferable  to  infiltrate 
layer  by  layer  according  to  the  first  plan  recommended.  After 
the  sac  is  exposed  the  tissues  about  the  internal  ring  are  sepa- 
rately injected  (Fig.  91),  and  may  then  be  incised  with  impunity. 
Strangulated  loops  of  gut  are  not  sensitive  and  may  be  handled 
without  pain.  Above  the  line  of  strangulation  sensitiveness  may 
be  heightened. 

Strangulated  omentum,  if  it  has  retained  its  vitality  in  good 
measure  and  has  become  adherent  to  the  sac,  produces  pain 
when  manipulated.  Topography  is  apt  to  be  distorted  so  that 
accurate  localization  is  uncertain.  The  entire  field  about  the  in- 
ternal ring  must,  therefore,  be  blocked  off  preferably  with  /4% 
novocain-epinephrin  solution. 

The  use  of  local  anesthesia  does  not  alter  the  surgical  prob- 
lems involved.  If  the  gut  is  viable  it  is  returned  and  the  opera- 
tion terminated  by  complete  or  partial  closure.  If  necrotic  the 
gut  is  fixed  in  the  wound  to  be  resected  at  a  later  date  or  the  re- 
section and  anastomosis  may  be  proceeded  with  at  once. 

FEMORAL  HERNIA. — The  neural  anatomy  of  femoral  hernia  is 
such  that  nerve  blocking  cannot  be  employed,  and  dependence 
must  be  placed  upon  infiltration  without  regard  to  the  nerve  dis- 
tribution. 

An  elliptical  skin  line  is  infiltrated  about  the  hernia  with  a 
linear  extension  upward  and  outward  parallel  with  Poupart's 
ligament  (Fig.  92),  or  downward  parallel  with  the  saphenous 
vein.  The  former  is  suitable  for  the  performance  of  Selig's 
operation  and  the  latter  for  conventional  operations  with  or  with- 
out strangulation. 

From  the  initial  infiltration  line  in  the  skin  the  tissues  about 
the  tumor  are  injected  (a  and  b,  Fig.  92).  The  medial  side  can 
be  infiltrated  with  impunity,  but  the  close  proximity  of  the  fern- 


Surgical   Operations  with  Local  Anesthesia  205 

oral  vein  to  the  lateral  side  demands  caution  in  passing  the  needle. 
Anesthetization  of  the  neck  can  usually  be  accomplished  by  pass- 
ing the  needle  through  the  lower  edge  of  Poupart's  ligament. 
If  Seelig's  operation  is  to  be  performed  anesthetization  of  the  in- 
guinal canal  as  described  for  inguinal  hernia  should  be  added. 


Fig.  93.     Infiltration  of  the  tissues  about  Poupart's  ligament 

Infiltration  being  complete,  the  sac  is  exposed.  Sometimes  the 
manipulation  of  the  sac  is  still  painful  and  renewed  infiltration  of 
the  tissues  about  it  is  required.  With  the  sac  exposed  no  diffi- 
culty is  experienced  in  securing  anesthesia  by  edematizing  the 
surrounding  tissue.  The  sac  is  ligated  close  to  the  ligament  and 
the  wound  closed  in  the  usual  manner  or  Selig's  operation  may 
be  performed. 


206 


Surgical   Operations  with  Local  Anesthesia 


In  cases  of  strangulation  the  surrounding  tissues  are  often  ede- 
matous  and  a  more  extensive  infiltration  is  required.  These  often 
are  usually  small  and  it  is  usually  most  convenient  to  edematize 
the  tissue  about  the  tumor  independent  of  the  surrounding  struc 


Pig:.  94.     Poupart's  ligament  is  being:  cut  with  scissors  before  the  sac  is  opened. 


tures.  By  infiltrating  the  tissues  just  beneath  Poupart's  ligament 
the  tissues  about  the  neck  may  be  anesthetized  (Fig.  93).  It  is 
best  to  pass  the  needle  to  the  medial  side  of  the  neck  of  the  sac 
in  order  to  avoid  the  femoral  vein.  After  the  sac  is  exposed,  if 
it  is  not  yet  sufficiently  anesthetized,  additional  infiltration  may 


Surgical   Operations  with   Local  Anesthesia  207 

be  done.  In  order  to  release  the  constriction  about  the  neck  of 
the  sac  Poupart's  ligament  may  be  cut  through  (Fig.  94).  After 
the  sac  has  been  attended  to  the  cut  ends  of  Poupart's  ligament 


Fig.  !»o.     The  incision  in  Poupart's  ligament  is  closed  with  sutures.     These  sutures  in- 
clude the  iliac  fascia.     The  sutures  for  the  cl  >sure  of  the  ring  are  passed 
but  not  tied.     The  saphenous  vein  shows  at  the 
lower  end  of  the  opening. 

are  united  to  the  underlying  fascia.  In  addition  to  making  the 
operation  easier  this  method  closes  the  hernial  opening  (Fig.  95). 
These  recommendations  will  seem  purile  to  the  experienced  oper- 
ator, but  the  beginner  will  find  them  comforting. 


CHAPTER  XVI 
SACRAL  BLOCKING 

To  Cathelin  (Brilliere  et  Fills,  Paris,  1903,  also  translations 
by  Straus;  Entke,  Stadgart,  1903)  belongs  the  credit  for  first  in- 
vestigating the  feasibility  of  producing  surgical  anesthesia  by 
introducing  a  solution  extradurally.  He  used  cocain  and  was 
enabled  to  induce  anesthesia  over  the  entire  body  of  a  dog  by 
the  use  of  3  cc.  of  i%  solution.  In  the  human  subject  he  injected 
the  solution  through  the  hiatus  sacralis  into  the  sacral  canal,  but 
was  unable  to  produce  satisfactory  results  with  safe  quantities  of 
the  anesthetic.  Stockel  (Zentralbl.  F.  Gyndk,  1909,  XXXI,  i) 
further  developed  the  method  by  using  the  less  toxic  eucain  and 
novocain.  By  the  use  of  30  cc.  of  0.5%  novocain  solution  he  was 
enabled  to  reduce  the  pains  of  parturition  materially. 

In  1910  Lawen  modified  the  technic  of  Cathelin  and  Stockel, 
and  was  enabled  to  produce  constant  results.  It  had  previously 
been  shown  by  anatomists  and  by  the  injection  experiments  of 
Cathelin  and  others,  that  the  epidural  space  surrounding  the 
dura  from  the  hiatus  to  the  foramen  magnum  comprised  the  area 
between  the  dura  and  the  internal  periosteum  and  ligaments  of 
the  canal.  Liiwen,  desirous  of  confining  the  action  of  his  solu- 
tion to  the  lower  part  of  this  canal,  injected  his  patients  while  in 
the  sitting  position,  or  made  the  injection  in  the  lateral  position 
and  then  allowed  them  to  sit  upright  until  anesthesia  was  induced. 
He  increased  the  concentration  of  his  solution  and  determined 
that  less  than  iy2  to  2%  solutions  were  not  effective.  In  order  to 
reach  nerves  high  enough  in  the  canal  he  determined  that  at 
least  20  cc.  of  the  solution  was  required.  Gros  (Munchen.  med. 
Wchnschr,  1910,  LVII,  2042)  showed  that  the  efficiency  of  the 
solution  could  be  increased  by  the  addition  of  sodium  bicarbonate. 

TECHNIC. — The  sacral  canal  terminates  below  in  the  hiatus  sac- 
ralis, a  trangular  opening  the  sides  of  which  are  marked  by  the 

208 


Surgical   Operations  zvith  Local  Anesthesia 


209 


sacral  cornua.  This  opening  varies  in  size.  It  may  be  greatly 
enlarged  by  the  failure  of  one  or  more  of  the  arches  to  close, 
and  may  be  reduced  in  size  by  an  osseous  bar  and  even  entirely 
closed  by  osseous  changes  in  the  membrane  which  covers  it.  The 
hiatus  is  normally  covered  by  the  posterior  sacrococcygeal  liga- 
ment. By  passing  the  finger  along  the  spines  of  the  sacrum  from 
above  downward  this  membrane  is  usually  readily  palpated. 
Lawen  has  aptly  compared  the  sensation  this  membrane  produces 
when  palpated  with  that  of  a  fontanelle.  Even  in  fat  persons  the 


Fig.  !I(J.     Position  of  the  patient  in  sacral  blocking.     (Lawen). 

depression  can  be  noted  with  considerable  distinctness.  When 
this  is  not  possible  one  can  find  the  hiatus  with  the  needle  by 
gently  feeling  the  way  into  the  canal  much  as  one  searches  for 
the  foramen  ovale  when  injecting  the  Gasserian  ganglion.  By 
this  means  the  canal  can  always  be  found  and  one  need  not,  as 
Liiwen  does,  exclude  fat  persons  from  the  use  of  this  method. 

It  is  most  convenient  to  place  the  patient  in  the  left  lateral 
position  with  the  knees  drawn  up  (Fig.  96).  The  finger  of  the  left 
hand  locates  the  hiatus.  A  syringe  armed  with  a  small  needle  is 
then  used  to  anesthetize  the  skin  and  to  locate  the  hiatus  accur- 
ately. It  is  not  difficult  to  recognize  the  foramen.  The  needle 


2io  Surgical   Operations  with   Local  Anesthesia 

meets  an  elastic  resistance  quite  unlike  that  offered  by  bone.  A 
little  increase  in  pressure  forces  the  needle  through,  and  it  then 
passes  without  resistance.  The  sensation  is  like  that  produced 
by  passing  the  needle  through  the  pleura  into  a  pleural 
exudate.  When  the  foramen  has  been  located  the  small  needle 
is  withdrawn  and  a  larger  and  longer  one  substituted.  If  one 
regards  the  feeling  of  the  patient  less,  the  larger  needle  may  be 
used  throughout. 

The  depth  to  which  the  needle  enters  must  be  noted.  The  ter- 
mination of  the  dural  sac  is  at  the  2d  or  3d  sacral  vertebra,  which 
is  from  6  to  9  cm.  from  the  hiatus.  As  soon  as  the  needle  passes 
the  membrane  it  is  in  the  canal.  Inasmuch  as  the  closure  of  the 
canal  is  not  complete  it  is  desirable  to  deposit  the  fluid  as  near 
the  nerve  roots  as  possible  without  endangering  the  dural  sac. 
From  the  measurements  above  quoted  a  depth  of  6  cm.  would 
seem  to  be  entirely  safe.  An  ordinary  needle  may  be  used,  but 
in  order  to  avoid  injury  to  the  venous  plexus  which  fills  the  canal, 
Schlimpert  (Zentral  P.  Gynak,  1911,  XXXV,  477)  uses  a 
needle  constructed  like  a  trocar.  After  the  membrane  is  per- 
forated the  sharp  point  is  withdrawn  and  the  needle  pushed  up- 
ward. With  such  a  needle  the  danger  of  wounding  the  dural  sac 
is  obviated. 

Instead  the  needle  may  be  introduced  within  the  canal  and 
the  empty  syringe  attached.  The  piston  is  then  partly  with- 
drawn, so  that  a  vacuum  is  produced  in  the  barrel  of  the  syringe, 
and  the  needle  slowly  passed  upwards.  If  the  spinal  canal  or  a 
blood  vessel  should  be  entered,  the  accident  is  made  manifest 
by  the  appearance  of  their  respective  contents  in  the  barrel 
of  the  syringe.  Should  this  occur,  the  direction  of  the  needle 
must  then  be  altered.  After  the  needle  has  entered  to  a  proper 
depth,  the  syringe  is  filled  with  the  anesthetic  fluid  and  reat- 
tached  to  the  needle  and  its  contents  slowly  injected.  At  least 
20  cc.  of  the  solution  must  be  used. 

When  a  sharp  needle  is  used  the  dural  sac  may  be  avoided  by 
directing  the  needle  to  one  side  or  other  of  the  median  line  (Fig. 


Surgical   Operations  with  Local  Anesthesia 


211 


97).  Likewise,  in  order  to  avoid  perforating  the  nerve  roots,  the 
outside  end  of  the  needle  should  be  moved  toward  the  body  after 
the  membrane  is  past,  in  order  that  the  point  may  approach  the 
posterior  wall  of  the  canal.  In  order  to  injure  the  vessels  as  little 
as  possible,  injection  of  the  fluid  begins  as  soon  as  the  needle 
passes  the  membrane  and  continues  slowly  as  the  needle  grad- 


Fig.  97.     Direction  of  the  needle  in  sacral  blocking.     (Lawen). 

ually  passes  upward.  In  this  manner  the  veins  are  to  a  certain 
extent  pushed  away  from  the  point  of  the  needle.  Should  a 
vein  be  punctured  only  a  small  quantity  of  fluid  would  be  injected 
into  it  before  the  needle  passes  on  through  it.  In  this  way  20  cc 
of  the  fluid  are  injected  in  the  course  of  two  minutes. 

SOLUTION  USED. — According  to  the  investigations  of  Gros  the 
addition  of  sodium  bicarbonate  causes  the  novocain  to  pene- 
trate more  readily  into  the  nerve  sheaths.  Lawen,  on  the  basis 
of  abundant  experience,  recommends  the  following : 


212  Surgical   Operations  with  Local  Anesthesia 

Sodium  bicarbonate  0.15 

"        chloride  o.i 

Novocain  0.6 

This  is  prepared  in  a  powder  and  is  dissolved  in  30  cc.  of 
water.  This  gives  a  2%  novocain  solution  of  which  20  cc.  is 
injected. 

He  also  uses  a  weaker  solution  as  follows : 

Sodium  bicarbonate  0.2 

"       chloride  0.2 

Novocain  0.75 

This  is  dissolved  in  50  cc.  of  water  to  make  a  1^/2%  solution  of 
which  20  to  25  cc.  is  injected. 

The  solution  is  prepared  by  dissolving  the  powder  in  the 
given  amount  of  cold  water  and  bringing  it  to  the  boiling  point. 
This  brief  heating  assures  a  sterilization,  according  to  Ljiwen,  and 
increases  its  efficiency  due,  according  to  Gros,  to  the  fact  that  the 
heating  converts  a  part  of  the  bicarbonate  into  carbonate  which 
is  still  more  hydrolytic.  After  the  solution  has  cooled,  5  drops 
of  i-iooo  adrenalin  solution  is  added.  Strauss  (Ztschr.  f. 
Geburtsh.  u.  Gyn  k,  1912,  LXXII,  163)  adds  sodium  sulphate 
to  prevent  a  decomposition  of  the  adrenalin. 

EXTENT   AND   DURATION    OF    ANESTHESIA. — Anesthesia    becomes 

complete  in  about  20  minutes.  It  is  first  noted  at  the  tip  of  the 
coccyx  and  extends  over  the  perineum,  and  laterally  over  the 
gluteal  region.  The  region  of  the  clitoris  and  glans  penis  are  the 
last  to  become  anesthetic,  and  in  partial  failure  it  is  these  regions 
that  fail  to  become  anesthetized.  In  other  words,  the  coccygeal 
plexus  is  the  first  to  become  anesthetized,  then  the  hemorrhoidal 
and  perineal,  and  lastly  the  dorsalis  penis.  The  cause  of  the  occa- 
sional partial  failure  to  reach  the  latter  is  that  they  come  from  the 
pudendal  plexus  which  sometimes  derives  roots  from  as  high  as 
the  first  sacral  segment.  In  addition  the  middle  hemorrhoidal, 
vaginal  and  inferior  vesical  nerves  are  usually  anesthetized.  The 


Surgical   Operations  with  Local  Anesthesia  213 

extent  of  the  anesthesia  of  the  latter  nerves  is  often  difficult  to 
determine  since  operations  upon  these  tissues  involves  more  or 
less  traction  which  may  produce  pain  in  regions  beyond.  In  opera- 
tions upon  the  rectum,  such  as  high  fistula,  or  in  amputations 
when  no  traction  is  produced,  no  pain  is  experienced  by  the 
clamping  and  cutting  manipulations.  The  prostate  also  is  insen- 
sitive to  incision,  but  not  to  traction.  Paralysis  of  the  motor 
nerves  aids  materially  in  retraction.  The  sphincter  and  levator 
ani  become  lax  and  the  parts  above  are  reached  with  greater 
facility  than  when  operating  under  general  anesthesia,  but  even 
with  this  aid  the  higher  operations  in  the  pelvis  may  cause  pain. 
By  using  the  Trendelenburg  position  Schlimpert  &  Schneider 
(Munchcn.  mcd.  Wehnschr.,  1910,  LVII,  2561),  have  secured 
anesthesia  as  high  as  the  umbilicus.  In  this  position  anesthesia 
seems  to  begin  sooner,  but  is  less  certain  than  in  the  sitting 
position. 

Schlimpert  &  Schneider  have  found  sacral  anesthesia  useful 
in  securing  relaxation  during  labor  in  old  primipara.  They  have 
not  found  that  the  intensity  of  the  labor  pains  is  influenced  by 
sacral  anesthesia.  They  used  50  ccm.  of  a  i%  solution. 

The  duration  of  anesthesia  is  from  40  minutes  to  2  hours  and 
often  longer.  Sensation  to  touch  often  returns  before  that  of 
pain  and  the  sensations  may  be  confused  by  the  patient.  The 
anesthesia  usually  subsides  in  the  inverse  order  of  its  beginning; 
that  is,  the  glands  and  clitoris  first  regain  their  sensation  and  the 
ano-coccygeal  region  last. 

EFFICIENCY  AND  FAILURES. — Ljiwen  (Deutsch.  ztschr.  f,  Chir., 
1911,  CVIII,  i)  gives  detailed  reports  of  80  cases  among 
which  there  were  /  failures.  His  operations  comprised 
hemorrhoids,  melanosarcoma  of  the  anus,  fistulas,  hypospadias 
and  phimoses.  Schlimpert  &  Schneider  (/.  c.)  reported  34  opera- 
tions comprising  perineal  repairs,  currettage  of  inoperable  car- 
cinomas, and  rectoscopy,  and  cystoscopy.  They  recommend  it 
for  forceps  operations  and  for  the  repair  of  obstetric  lacerations. 
To  these  Schlimpert  (Zcntralbl.  f.  Gynak.,  1911.  XXXV,  477), 


214  Surgical   Operations  with  Local  Anesthesia 

adds  55  cases  in  which  there  were  n  failures.  In  12  general 
anesthesia  had  to  be  added  because  of  the  long  duration  of  the 
operation.  In  these  cases  the  Trendelenburg  position  was  used. 
My  own  experience  with  sacral  blocking  has  convinced  me  of 
the  value  of  the  method  in  perineal  operations.  It  sometimes  fails 
more  or  less,  but  if  one  is  ready  to  supplement  the  sacral  blocking 
by  local  infiltration  the  shortcomings  of  the  method  do  not  work 
much  of  a  hardship.  My  plan  is  to  use  quinine  in  the  sacral 
canal  and  novocain-epinephrin  for  local  infiltration,  or  novocain 
in  the  canal  and  quinine  for  local  infiltration.  In  this  man- 
ner it  is  possible  to  meet  all  indications  without  using  an  excess 
of  the  novocain-epinephrin  solution.  By  using  this  combined 
method  I  have  never  had  to  resort  to  general  anesthesia. 

The  advantages  of  adding  sacral  anesthesia  to  any  operation  in 
the  area  supplied  by  the  sacral  plexus  is  apparent.  It  is  partic- 
ularly to  be  desired  where  extensive  operations  are  to  be  done, 
such  as  the  Freund-Werthheim  operation,  prostatectomy  or  the 
resection  of  rectal  carcinomas. 

I  have  found  the  method  uniformly  useful  in  the  cystoscopic 
examinations  of  males  or  for  the  sounding  of  structures.  For 
this  purpose  partial  failures  do  not  work  as  a  great  inconvenience 
and  since  the  patient  is  in  comparative  comfort  there  is  no  dis- 
position to  hurry  the  examination.  Retention  of  urine  has  not 
followed  its  use  in  my  experience. 

The  usual  cause  of  failure,  aside  from  such  gross  errors 
as  injecting  the  fluid  outside  the  canal  or  into  a  vessel,  results 
from  the  use  of  a  too  small  amount  of  fluid.  Two  ounces  of  a 
YZ  per  cent,  solution  gives  more  certain  results  than  half  this 
amount  of  twice  the  strength.  In  passing  the  needle  higher  up. 
under  the  precautions  previously  mentioned,  and  the  vise  of  a 
large  amount  of  the  weaker  solutions,  few  failures  will  result. 

Untoward  complications  are  few  and  unimportant.  The 
needle  may  be  broken  off  by  the  sudden  movement  of  the 
patient.  This  is  unlikely  to  occur  unless  old  rusty  needles  are 
used.  Sometimes  the  patient  shows  a  degree  of  restlessness, 


Surgical   Operations  with  Local  Anesthesia  215 

but  this  soon  passes  off.  The  large  nerve  trunks  of  the  legs  may 
be  anesthetized.  This  may  result  in  complete  sensory  anesthesia 
and  may  affect  the  motor  fibers  to  the  extent  that  the  patient 
is  unable  to  walk  for  several  hours.  This  soon  passes  off,  how- 
ever. This  involvement  of  the  leg  nerves  occurs  only  when  the 
injections  are  made  high  and  a  large  amount  of  fluid  is  used. 
In  the  use  of  quinine,  therefore,  not  over  20  or  30  cc.  should 
be  used  unless  prolonged  action  is  desired. 


CHAPTER  XVII 
OPERATIONS  ON  THE  PENIS 

CIRCUMCISION. — Removal  of  the  redundant  foreskin  is  usually 
the  operation  which  furnishes  the  first  lesson  for  the  beginner  in 
local  anesthesia.  Simple  as  the  operation  is,  careful  technic  is 
required  in  order  to  avoid  many  annoyances  during  its  course 
and  afterward. 

The  foreskin  is  supplied  by  the  dorsalis  penis  nerve  which 
enters  the  dorsum  at  the  root  and  sends  branches  which  supply- 
both  the  cutaneous  and  mucous  surfaces. 

A  rich  plexus  of  veins  lies  between  the  skin  and  mucous  sur- 
faces and  at  the  frenulum  is  an  artery  which  always  requires 
ligation.  Smaller  and  less  constant  arteries  are  found  on  the 
dorsal  or  lateral  aspects. 

The  usual  error  in  circumcision  is  that  the  skin  is  anesthetized 
but  the  mucous  membrane  is  neglected.  The  frenulum,  too,  sen- 
sitive as  it  is,  is  often  overlooked.  The  skin  is  too  thin  to  permit 
endermic  infiltration  and  subdermic  injection  must  be  depended 
upon. 

With  the  foreskin  in  its  normal  position  a  line  *4  to  y$  inch 
wide  is  infiltrated  just  back  of  the  corona  of  the  glans  (a,  Fig. 
98).  Some  care  is  needed  in  order  that  a  perfect  circle  is  de- 
scribed. 

The  foreskin  is  then  fully  retracted  and  a  line  is  injected  in  a 
like  manner  in  the  mucous  membrane  about  %  mcn  proximal  to 
the  corona  glandis  (Fig.  99).  The  frenulum  is  then  injected  from 
the  line  in  the  mucous  membrane  to  the  glans  (Fig.  100). 

The  foreskin  is  then  returned  to  its  normal  position  and  the 
skin  is  snipped  through  with  scissors  (Fig.  101).  The  skin  alone 
is  cut.  The  fluid  injected  raises  the  skin  from  the  veins  and  it  is 
possible  to  sever  the  skin  without  cutting  the  veins.  The  skin  is 
now  snipped  from  the  vessels  and  subcutaneous  tissue  until  the 
line  of  infiltration  in  the  mucosa  is  reached  (Fig.  102).  By  this 
means  most  of  the  veins  retract  with  the  subcutaneous  tissue  and 

216 


Surgical   Operations  zcitJi  Local  Anesthesia  219 

are  not  severed.  The  mucosa  is  then  cut  with  snips  of  the  scissors 
about  l/4  inch  from  its  insertion  (Fig.  103).  The  frenulum  is  cut 
not  more  than  y&  inch  from  the  glans. 

The  artery  of  the  frenulum  and  any  other  bleeding  points  are 
caught  up  and  ligated.  Exact  hemostasis  must  be  accomplished 
before  suturing  is  begun.  If  this  detail  is  not  observed  oozing 
in  the  loose  tissue  will  cause  swelling,  discoloration  and  delayed 
healing.  In  some  instances  the  hemorrhage  may  soak  the  dress- 
ings and  be  the  cause  of  embarrassment  to  both  patient  and  opera- 
tor. The  most  certain  way  of  securing  all  bleeding  points  is  to 
catch  them  up  the  moment  they  are  cut. 

The  mucosa  and  skin  are  then  united  with  fine  catgut  (Fig. 
104).  The  sutures  should  be  placed  close  together  so  that  there 
will  be  no  gaping  spaces.  A  little  attention  to  this  detail  brings 
a  smoother  recovery  and  well  repays  the  extra  time  spent.  A 
simple  gauze  dressing  completes  the  operation. 


Fig.  104.     Union  of  skin  and  mucosa  with  interrupted  sutures. 

Complications  do  not  arise  if  hemostasis  has  been  carefully  per- 
formed. The  sutures  occasionally  become  infected,  but  this  de- 
lays healing  for  a  few  days  only. 

Quinine  is  the  anesthetic  of  choice  but  novocain-epinephriu 
may  be  used  with  satisfaction.  The  latter  by  giving  a  bloodless 
field  makes  the  operation  simpler,  but  there  is  more  after-pain  and 
more  disposition  to  ooze.  Complaint  has  been  made  that  qui- 
nine causes  necrosis  of  the  skin  or  fails  to  give  perfect  anesthe- 
sia. The  first  fault  is  due  to  the  use  of  too  great  amount  of  fluid, 
the  latter  the  failure  to  place  the  fluid  in  the  right  place.  The  in- 


22O  Surgical   Operations  with  Local  Anesthesia 

j action  must  be  made  immediately  beneath  the  skin  or  mucous 
membrane  respectively.  Merely  throwing  the  solution  aimlessly 
into  the  loose  connective  tissue  of  the  foreskin  will  not  produce 
satisfactory  results.  For  those  who  must  go  about  their  business 
immediately  after  the  operation,  quinine  is  certainly  the  anesthe- 
tic of  choice. 


Fig.  105.     Line  of  infiltration  for  amputation  of  the  penis  and  removal  of  the  inguinal 
glands.     At  the  points  x  x,  the  tissue  about  the  root  of  the  penis  is  infiltrated. 

AMPUTATION  OF  THE  PENIS. — Carcinoma  presents  practically 
the  only  indication  for  this  operation.  The  inguinal  glands  re- 
quire preliminary  removal  in  all  instances.  It  is  convenient, 
therefore,  to  begin  the  anesthesia  by  injecting  the  inguinal  canai. 
This  is  accomplished  by  a  line  from  a  point  a  short  distance  inter- 
nal to  and  below  the  anterior  superior  spine,  continued  along  the 
direction  of  the  inguinal  canal,  crossing  above  the  pubes  and  de- 
scribing a  line  along  the  opposite  inguinal  canal  (Fig.  105).  From 


Surgical   Operations  with  Local  Anesthesia 


221 


this  primary  line  the  deeper  tissues  are  infiltrated  as  for  hernia, 
also  about  the  root  of  the  penis  (x,  x,  Fig.  105).  The  region  of 
the  external  abdominal  rings  receives  particular  attention.  The 
cord  must  be  effectually  blocked  as  in  operations  upon  the  cord. 


Fig.  1(X>.     Line  of  infiltration  about  the  root  of  the  scrotum.     The  deep  tissues  are  inject- 

ted  at  the  points  x,  x.     The  transverse  line  shown  in  the  previous  figure 

is  shown  in  the  background. 

The  scrotum  is  now  raised  and  the  skin  across  the  root  of  the 
penis  is  infiltrated  from  one  side  to  the  other  (Fig.  106).  The 
root  of  the  penis  is  now  infiltrated  by  passing  the  needle  medial  to 
the  pubic  arch,  reaching  the  dorsalis  penis  at  the  root  of  the  penis 
beneath  the  arch  (x,  x,  Fig.  106).  This  is  the  most  important 
point  of  injection  and  several  cc.  of  the  fluid  should  be  deposited 
in  the  vicinity  of  the  nerve.  This  done  the  entire  penis  and 
scrotum,  together  with  the  contents  of  the  latter,  is  anesthetized 
and  any  operation  required  may  be  done. 


CHAPTER  XVIII 
OPERATIONS  ON  THE  SCROTUM  AND  ITS  CONTENTS 

The  scrotum  is  supplied  by  the  ilio-inguinal  nerves  at  its  upper 
part  and  by  the  perineal  nerves  at  the  lower  portion.  The  scrotal 
contents  are  innervated  by  the  genital  branch  of  the  genito-crural 
and  the  sympathetic  nerves  from  the  aortic,  renal  and  hypogastric 
plexuses.  Because  of  the  abundant  nerve  supply  to  the  scrotum, 
incisions  into  it  are  best  preceded  by  injections  into  the  line  of 
the  proposed  incision.  The  nerve  supplying  the  scrotal  contents 
may  be  blocked  in  any  part  of  the  cord.  This  may  be  most  easily 
done  just  below  the  external  ring. 

VARICOCELE. — Operations  for  varicocele  have  for  their  object 
the  obliteration  of  the  veins  of  the  pampiniform  plexus,  varicosi- 
ties  of  which  constitute  the  prominent  objective  symptom  of  the 
disease.  Prominent  factors  in  the  symptomatology  are  the  back- 
ache and  certain  psychic  disturbances  preceding,  accompanying 
or  following  the  pampiniform  dilatation.  Relaxation  of  the  scro- 
tum, which  permits  the  weight  of  the  testicle  to  tug  constantly 
upon  the  cord,  is  responsible  in  a  large  measure  for  the  backache 
and  perhaps  for  some  of  the  psychic  disturbances.  The  require- 
ments of  the  operation  in  any  given  case  will  depend  upon  the 
conditions  present.  If  the  scrotal  relaxation  is  marked  this  re- 
quires attention.  If  the  vessels  alone  are  affected  the  resection 
of  these  only  will  give  the  desired  result.  The  ideal  operative 
scheme  must  be  such  that  each  of  these  may  be  given  the  atten- 
tion the  conditions  present  demand.  Any  of  the  classical  opera- 
tions may  be  done  with  satisfaction  under  local  anesthesia.  The 
operation  here  proposed  has  the  merit  that  both  factors  in  the 
disease  may  be  given  attention  through  a  single  small  incision. 

RESECTION  OF  THE  VEINS. — Beginning  immediately  below  the 
base  of  the  scrotum  a  line  is  infiltrated  in  the  general  direction 

222 


Surgical   Operations  with  Local  Anesthesia  223 

of  the  cord  (Fig.  107),  extending  downward  i*/2  inches.  This 
anesthetizes  the  cutaneous  nerves  only,  which,  it  will  be  remem- 
bered, are  branches  from  the  sacral  plexus  through  the  perineal 


Fig.   107.     Line  ot  skin  infiltration. 


nerves.  The  scrotal  contents  are  supplied  by  the  nerves  accom- 
panying the  cord  through  the  inguinal  canal.  At  the  point  of 
operation  they  have  divided  into  branches  too  fine  to  be  infil- 


224  Surgical  Operations  with  Local  Anesthesia 

trated  directly.  Perineural  blocking  must  therefore  be  resorted 
to.  This  is  done  by  grasping  the  cord  between  the  thumb  and 
finger  at  the  base  of  the  scrotum  and  making  firm  pressure  (Fig. 


I'ig.   108.     Method  of  grasping  the  cord  for  blocking 


108).  The  needle  is  passed  at  the  upper  end  of  the  line  already 
infiltrated  into  the  tissues  imprisoned  between  the  thumb  and 
finger.  About  2  cubic  centimeters  (30  minims)  is  injected  at  this 


Surgical   Operations  with  Local  Anesthesia  225 

point.    This  effectually  blocks  all  the  nerves  leading  to  the  scrotai 
contents. 

The    incision    is    then   begun    in    the   line   already    infiltrated. 


Fig.  109.     The  tunica  vaginalis  has  been  incised  and  is  being  held  by  forceps  and 
the  veins  selected  for  extirpation  are  being  ligated. 

Branches  of  the  external  pudic  artery  are  severed  and  should  be 
ligated  at  once.  The  tunica  vaginalis  is  identified  and  held  by 
forceps  (Fig.  109).  The  cord  with  the  enlarged  veins  is  sepa- 


226 


Surgical  Operations  with  Local  Anesthesia 


rated  from  its  sheath  and  all  structures  identified.  The  vas 
deferens  with  its  accompanying  artery  and  several  small  veins 
are  separated  to  be  preserved.  Included  with  these  are  a  number 
of  nerve  filaments.  The  bundle  of  veins  remaining  is  to  be  re- 


rig.  110.     The  severed  ends  of  the  veins  are  united  by  sutures. 

sected.  The  veins  are  freed  from  the  vas  and  its  accompanying 
structures  for  a  distance  greater  than  the  amount  of  tissue  to  be 
removed.  The  upper  and  lower  limits  are  then  tied  with  catgut 


Surgical   Operations  with  Local  Anesthesia 


22: 


and  the  intervening  tissue  removed.  The  severed  ends  are  then 
united  by  tying  the  ends  of  the  ligatures  together  and  additional 
security  is  assured  by  passing  supplemental  stitches  through  the 
stump  (Fig.  no).  The  tunica  vaginalis  is  now  closed  by  a  sep- 


fig.  111.     Closure  of  the  incision  hi  the  tunica  vaginalis  in  a  transverse  direction. 

arate  line  of  sutures  (Fig.  in).     The  skin  is  closed  in  a  longi- 
tudinal direction    (Fig.    112)    by  either  catgut  or  silk. 

By  closing  the  longitudinal  incision  in  the  tunica  transversely  a 


228  Surgical  Operations  with  Local  Anesthesia 

shortening  equal  to  the  length  of  the  incision  is  secured.  By 
varying  the  length  of  the  incision  any  degree  of  shortening  may 
be  secured.  By  this  means  a  fascial  support  is  secured  for  the 


Fig.  112.     Closure  of  the  skin  incision  by  interrupted  sutures. 

testicle.     The  results  are  the  same  as  those  secured  by  scrotal 
amputation  without  the  need  of  a  skin  resection. 

Instead  of  injecting  the  cord  through  the  unopened  skin  the 
cord  may  be  separated  after  incision  of  skin  and  tunica  and  then 


Surgical   Operations  zvith  Local  Anesthesia  129 

grasped  between  the  thumb  and  finger  and  injected.  This  method 
is  more  easily  accomplished,  but  the  separation  of  the  cord  before 
injection  is  accompanied  by  some  pain. 

Either  novocain-epinephrin  or  quinine  may  be  used.  The  for- 
mer gives  a  bloodless  field,  but  is  more  apt  to  be  followed  by 
late  oozing.  Quinine  has  the  advantage  of  freedom  from  late  ooz- 
ing, but  if  too  much  is  used  an  induration  is  produced  about  the 
site  of  incision  which  may  excite  the  curiosity  of  the  patient. 
This  always  subsides  after  a  few  weeks. 

AMPUTATION  OF  THE  SCROTUM. — If  preferred  the  classical  am- 
putation of  the  scrotum  may  be  performed.  Ordinarily  the 
degree  of  shortening  is  estimated  and  the  distance  determined  is 
clamped  off  with  long-bladed  forceps.  Moynihan's  intestinal 
forceps  are  excellent  for  this  purpose.  The  skin  below  the  for-- 
ceps  is  then  infiltrated  with  quinine  or  novocain-epinephrin,  and 
the  amputation  proceeded  with,  the  clamps  being  still  in  position 
Through  and  through  sutures  are  then  placed  and  tied. 

Since  the  shortening  of  the  tunica  alone  is  of  importance  and 
the  removal  of  the  skin  incidental  and  unimportant  the  clamps 
are  best  avoided,  because  when  they  are  placed,  the  tunica  is  apt 
to  retract  and  the  purpose  of  the  operation  is  defeated.  The  fol- 
lowing method,  therefore,  is  to  be  recommended  as  permitting 
the  operator  to  remove  with  greater  exactness  the  desired  amount 
of  the  tunica. 

The  amount  of  the  scrotum  to  be  amputated  is  estimated  by 
drawing  the  redundant  portion  between  the  fingers.  If  the  opera- 
tor doubts  his  ability  to  follow  the  imaginary  line  so  formed  it 
will  be  well  to  paint  a  line  with  tincture  of  iodine.  This  line  is 
then  anesthetized  about  the  entire  circumference  of  the  scrotum. 
The  skin  is  then  cut  through  to  the  tunica  with  scissors.  The 
tunica  is  then  taken  up  and  the  amount  to  be  removed  estimated 
by  drawing  it  between  the  fingers.  The  tissue  is  anesthetized 
while  the  grasp  is  retained.  The  portion  representing  the  inter- 
testicular  septum  should  receive  special  attention  because  nerves 
are  abundant  at  this  point.  The  excision  of  the  tunica  is  then 


230  Surgical   Operations  with  Local  Anesthesia 

completed,  care  being  taken  to  secure  the  sac  from  retraction ; 
any  bleeding  points  are  caught  up  and  ligated  as  they  are  cut, 
Careful  hemostasis  should  now  be  made  in  order  to  secure  every 
bleeding  point.  Otherwise,  post-operative  hemorrhage  into  the 
sac  will  cause  embarrassment  during  convalescence.  The  two 
layers  of  the  tunica  are  united  with  catgut.  The  skin  is  then 
united  as  a  separate  layer,  preferably  by  non-absorbable  sutures. 
Since  hemostasis  has  been  accomplished  by  separate  ligatures 
the  skin  sutures  should  be  only  tight  enough  to  secure  appositon 
of  the  skin.  Care  on  this  point  will  greatly  shorten  the  period  of 
convalescence  from  the  operation. 

HYDROCELE. — In  the  radical  operation  for  hydrocele  the  same 
skin  infiltration  is  employed  as  in  the  varicocele  operation ;  but  it 
is  placed  lower,  and  may  be  lengthened  with  advantage.  The 
incision  is  made  through  the  skin  down  to  the  tunica  vaginalis. 
The  cord  is  exposed  above  the  tunica,  and  loosened  carefully  with 
finger  and  forceps  until  it  can  be  grasped  between  the  thumb  and 
finger.  The  injection  is  then  made  as  in  varicocele.  The  cord 
may  be  infiltrated  before  making  the  skin  incision  as  in  varicocele 
if  the  tunica  is  not  so  large  as  to  make  the  cord  inaccessible  to 
the  grasp  of  the  fingers. 

With  the  infiltration  of  the  cord  the  entire  area  becomes  insen- 
sitive and  the  tunica  can  be  separated  with  ease  and  the  desired 
resection  made.  Care  must  be  taken  to  make  the  separation  just 
external  to  the  tunica  for,  if  the  separation  is  made  between  the 
skin  and  the  dartos,  pain  will  result,  because  the  skin  of  the  lower 
scrotal  region  is  supplied  by  the  perineal  nerves,  which  are  un- 
affected by  the  anesthetization  of  the  nerves  accompanying  the 
spermatic  cord.  For  the  same  reason,  if  it  is  desired  to  drain 
the  base  of  the  scrotum,  the  skin  must  be  anesthetized  at  the  de- 
sired point  of  incision.  For  the  ordinary  hydrocele  operation  a 
drain  is  not  required.  An  interrupted  non-absorbable  suture, 
after  all  hemorrhage  has  been  controlled,  should  be  used  to  close 
the  wound. 


Surgical   Operations  with   Local  Anesthesia  231 

CASTRATION. — The  removal  of  the  testicle  is  the  simplest  opera- 
tion upon  the  external  genitals  to  be  performed  under  local  anes- 
thesia. The  technic  required  consists  merely  in  exposure  and 
ligation  of  the  cord.  This  may  be  accomplished  at  the  base  of 
the  scrotum  or  in  the  inguinal  canal.  In  the  former  location  the 
technic  is  identical  with  the  first  steps  of  the  operation  for  vari^ 
cocele  and  in  the  latter  situation  the  cord  is  approached  as  in  the 
operation  for  inguinal  hernia. 

The  site  of  the  incision  will  be  dependent  upon  the  condition 
requiring  castration.  If  the  lesion  is  local,  as  in  hematocele,  ex- 
posure of  the  cord  at  the  base  of  the  scrotum  is  to  be  preferred. 
Castration,  however,  is  usually  done  for  malignant  disease. 

In  that  instance,  deep  infiltrations  about  the  inguinal  canal,  as 
for  large  inguinal  hernias,  gives  the  best  access  to  the  field.  The 
entire  thickness  of  the  abdominal  wall  must  be  infiltrated,  pre- 
ferably through  the  unopened  skin.  If  this  is  not  possible  the 
skin  and  subcutaneous  tissue  is  infiltrated  and  the  incision  then 
made  to  the  fascia  of  the  external  oblique.  The  remainder  of 
the  abdominal  wall  is  then  infiltrated.  This  latter  plan  is  the 
more  certain  for  beginners.  The  inguinal  canal  is  then  freely 
incised  and  the  cord  followed  under  the  peritoneum.  If  the 
castration  is  being  done  for  tuberculosis  the  vas  may  be  followed 
to  the  bottom  of  the  pelvis.  The  bloodless  field  secured  by  the 
epinephrin  is  particularly  gratifying  when  working  deep  in  the 
pelvis. 

VASECTOMY. — The  section  of  the  vas  is  done  to  prevent  the 
propagation  of  the  species.  It  is  now  confined  to  the  sterilization 
of  criminals  in  some  states,  but  the  signs  of  the  times  seem  to 
indicate  that  it  may  soon  have  a  wider  application. 

The  vas,  being  covered  only  by  the  skin  and  the  tunics  of  the 
cord,  is  easily  reached.  Grasped  by  the  thumb  and  finger,  either 
in  front  or  behind  the  scrotum,  it  is  infiltrated  with  quinine  or  no- 
vocain-epinephrin.  The  vas  is  exposed  with  a  few  strokes  of  the 
knife.  The  vas  is  then  infiltrated  with  a  few  drops  of  the  quinine 
or  novocain  solution.  This  is  necessary  because  of  the  density 


232  Surgical  Operations  with  Local  Anesthesia 

of  the  coats  of  the  vas;  diffusion  is  slow  and  if  the  vas  is  not 
thoroughly  anesthetized  the  patient  is  apt  to  feel  a  sickening  sen- 
sation when  it  is  severed.  A  section  of  the  vas  an  inch  long  is 
resected  and  the  ends  allowed  to  retract.  If  the  deferential 
artery  is  cut  it  must  be  carefully  ligated.  The  tunics  of  the  cord 
are  very  vascular  and  careful  hetnostasis  is  required  if  annoying 
infiltration  of  the  scrotum  is  to  be  avoided.  The  skin  is  closed 
with  a  suture  or  two  of  fine  catgut.  A  small  dressing  is  placed 
within  a  suspensory  and  the  patient  is  allowed  to  go  about  his 
business.  The  quinine  effectually  controls  the  after-pain  and  if 
hemostasis  is  perfect  there  is  no  annoyance. 


CHAPTER  XIX 

OPERATIONS  ON  THE  URETHRA,  BLADDER  AND  PROSTATE 

NEURAL  ANATOMY. — The  sensory  nerves  of  the  genito-urinary 
organs  are  the  same  as  those  of  the  rectum  and  anus.  They  are 
so  numerous  that  blocking  of  specific  nerves  is  uncertain,  and 
while  in  a  general  way  the  injection  may  be  massed  in  the  direc- 
tion of  the  chief  nerve  supply,  dependence  must  be  placed  upon 
infiltration  of  the  entire  region. 

LOCAL  ANESTHESIA  PRELIMINARY  TO  CYSTOSCOPIC  EXAMINATION. 

— Antipyrin  and  opium  and,  for  local  application,  cocain  were 
formerly  employed.  The  first  has  been  abandoned  because  of 
inefficiency,  and  the  last  because  of  its  dangers.  The  most  effi- 
cient safe  anesthetics  available  at  the  present  time  are  alypin  and 
quinine,  either  of  which  may  be  introduced  into  the  bladder  half 
an  hour  before  the  proposed  examination.  The  most  efficient 
method,  however,  is  the  blocking  of  the  sacral  canal,  which  in 
nearly  all  cases  gives  complete  anesthesia  of  the  parts  involved 
in  cystoscopic  examination.  In  intense  cystitis  with  spasmodic 
contractions  of  the  bladder  sacral  blocking  is  sometimes  ineffi- 
cient since  it  does  not  reach  the  bladder  wall  nor  the  peritoneum 
covering  it.  I  have  used  quinine  in  the  sacral  canal,  but  its  action 
is  less  prompt  than  novocain  and  the  effect  lasts  an  unnecessary 
length  of  time. 

EXTERNAL  URETHROTOMY. — When  the  stricture  can  be  passed 
the  bladder  may  be  filled  with  an  anesthetic  solution,  preferably 
i%  quinine  or  i%  alypin-suprarenin  solution  recommended  by 
Braun.  The  penile  urethra  is  filled  with  the  same  solution.  If 
the  stricture  is  impassable  the  part  of  the  urethra  distal  to  the 
point  of  stricture  may  be  filled  with  the  solution  and  retained 
with  a  tape.  Too  great  an  effort  to  secure  the  topical  effect  of 
the  local  anesthetic,  and  particularly  the  constricting  band,  may 
cause  more  pain  than  the  anesthetic  saves. 

233 


234  Surgical   Operations  with  Local  Anesthesia 

It  is  well  to  begin  the  anesthesia  by  infiltrating  the  skin  in  a 
line  over  the  part  of  the  urethra  affected.  This  point  is  indicated 
by  passing  a  sound  down  to  or  through  the  stricture.  The  parau- 
rethral  tissue  is  then  infiltrated  through  this  line.  By  sliding  the 
skin  to  one  side  the  tissue  of  the  penis  dorsal  to  the  urethra  can 
be  infiltrated.  The  operation  then  consists  in  resecting  the  con 
stricted  portion  of  the  urethra,  uniting  the  severed  ends  over  a 
permanent  catheter  and  closing  the  skin  wound  completely.  The 
operation  is  more  easily  done  under  local  than  under  general 
anesthesia  on  account  of  the  smaller  loss  of  blood.  Hemostasis 
must  be  carefully  secured  and  the  bulbus  must  be  protected  from 
injury,  on  account  of  its  tendency  to  ooze  after  theT^ffect  of  the 
epinephrin  wears  off. 

SUPRAPUBIC  CYSTOTOMY. — Initial  infiltration  is  made  along  the 
linea  alba  immediately  above  the  pubic  bone,  or  in  the  supra- 
pubic  fold  transversely  to  the  linea  alba.  The  prevesical  fat  is 
infiltrated  by  passing  the  needle  close  beneath  the  pubic  bone 
down  to  the  bladder  neck  and  laterally  over  the  bladder  wall, 
which  can  usually  be  recognized  by  careful  palpation  with  the 
needle. 

If  the  urethra  is  pervious  to  the  catheter  the  bladder  is  filled 
with  5%  quinine  or  with  1%  alypin  solution.  This  anesthetizes 
the  bladder  so  that  exploration  will  be  less  painful  and  raises 
the  fundus  of  the  bladder  so  that  it  is  more  readily  accessible. 
Local  anesthesia  is  very  difficult  in  cases  with  impassible  ure- 
thras, and  particularly  in  those  which  have  been  drained  by 
suprapubic  puncture  with  a  trocar.  In  such  cases  it  is  best  to  fill 
the  bladder  as  well  as  possible  through  the  trocar  canal.  Thor- 
ough infiltration  must  be  made  along  this  canal  because  the  sur- 
rounding inflammatory  tissue  is  not  only  painful,  but  also  hinders 
diffusion  of  the  anesthetic. 

The  incision  is  made  along  the  line  infiltrated  first  down  to 
the  bladder  wall.  If,  as  frecuiently  happens,  the  wall  is  still 
sensitive,  it  should  be  fixed  with  tenaculum  forceps  and  infiltrated 
separately.  If  the  bladder  wall  is  properly  injected  it  may  be 


Surgical    Operations  with   Local  Anesthesia  235 

cut  without  pain.  One  may  then  proceed  with  the  operation 
indicated,  introduction  of  a  drainage  tube,  extraction  of  a  stone, 
removal  of  a  tumor  or  of  the  prostate. 

EXTRACTION  OF  STONE. — If  the  bladder  mucosa  has  been  anes- 
thetized previously  the  stone  may  be  searched  for  and  removed 
without  pain.  If  that  preliminary  has  been  omitted  the  act  of 
grasping  the  stone  will  cause  pain. 

REMOVAL  OF  TUMORS. — After  the  bladder  has  been  opened  as 
described,  the  location  and  extent  of  the  tumor  can  be  seen  di- 
rectly. If  the  tumor  is  removable  the  bladder  wall  about  its  base 
is  infiltrated  and  the  tumor  removed  by  incision  or  cautery.  The 
suppression  of  bleeding  by  means  of  the  adrenalin  makes  this 
part  of  the  operation  simple. 

STONE  IN  THE  PELVIC  URETER. — Stones  in  the  lower  portion 
of  the  pelvic  ureter  can  be  reached  by  making  a  transverse  inci- 
sion as  for  suprapubic  cystotomy.  The  prevesical  tissue  is  then 
freely  infiltrated  beneath  the  peritoneum  down  to  the  bladder. 
Free  injection  of  fluid  about  the  bladder  wall  will  facilitate 
separation  of  the  paravesical  tissues  from  it,  so  that  the  pelvic 
ureter  may  be  exposed.  Abscesses  deep  in  the  broad  ligament, 
may  sometimes  be  reached  in  the  same  way. 

REMOVAL  OF  THE  PROSTATE. — I  have  not  removed  the  prostate 
through  the  bladder  under  local  anesthesia.  Allen  (New  Orleans, 
M.  ] .,  LXV  581)  proceeeds  as  follows:  He  opens  the  bladder 
under  local  anesthesia,  brings  the  prostate  into  view,  and  at  sev- 
eral points  between  the  true  and  false  sheath  injects  2  or  3  drams 
of  a  y2%  novocain  solution  with  15  minims  of  epinephrin  to  the 
ounce.  He  also  makes  injections  into  the  lateral  walls  of  the 
urethra  through  the  vesical  opening. 

PERINEAL  PROSTATECTOMY. — Two  methods  are  available.  The 
nerves  may  be  systematically  blocked  about  the  prostate  (Franke 
and  Posner),  or  at  the  sacral  foramina  (Braun).  Franke  and 
Posner  (Arch.  f.  Klin.  Chir.,  1912,  XCIX,  139)  proceed  as  fol- 
lows: with  the  finger  in  the  rectum  as  a  guide  the  needle  is 
introduced  2  or  3  cm.  lateral  and  slightly  ventral  to  the 


236  Surgical  Operations  with  Local  Anesthesia 

anal  opening.  The  coccyx  is  located  by  the  rectal  finger 
and  the  ligamentum  sacrospinosum  is  followed  to  the  spi- 
num  ossei  ischii.  The  needle,  which  must  be  12  to  15 
cm.  long,  is  passed  upward  until  it  reaches  the  levator-ani. 
Puncture  of  this  muscle  is  detected  by  the  patient  by  pain.  A  few 
cc.  of  the  fluid  are  deposited  here.  The  needle  is  passed  farther 
until  it  is  felt  to  impinge  on  the  ischial  spine.  It  is  then  slightly 
withdrawn  and  pushed  forward  again,  but  I  or  2  cm.  deeper  tl.~n 
before,  and  10  cc.  of  the  fluid  deposited.  The  needle  is  then  with- 
drawn until  the  point  lies  only  2  or  3  cm.  deep.  Its  direction  is 
then  changed  under  guidance  of  the  finger  upward  and  laterally 
to  the  space  between  the  rectum  and  prostate.  The  needle  is 
thrust  3  or  4  cm.  deeper  than  this  point  and  10  to  15  cc.  are  de- 
posited. The  same  process  is  repeated  upon  the  opposite  side. 
The  dorsalis  femoralis  nerve  is  injected  over  the  tuber  ischii. 
Anesthesia  comes  after  10  to  15  minutes.  Franke  and  Posner 
give  morphine  o.oi  gm.  or  twice  that  amount  of  pantopon  before 
the  operation. 

Braun's  technic  is  as  follows :  with  the  patient  in  a  lithotomy 
position  the  needle  is  introduced  at  a  point  1 1/2  to  2  cm.  lateral  to 
the  median  line  on  a  level  with  the  sacro-coccygeal  articulation, 
and  thrust  forward  parallel  to  the  ventral  surface  of  the  sacrum. 
The  operator  seeks  the  edge  of  the  sacrum  with  the  point  of  the 
needle,  feels  his  way  past  this  edge  and  pushes  the  needle  along 
the  flat  ventral  surface  of  the  sacrum  parallel  to  its  median  plane. 
The  needle  will  strike  the  forward  curve  of  the  upper  part  of 
the  bone  at  the  second  sacral  foramen,  6  or  7  cm.  from  the  point 
of  entrance.  The  entire  distance  from  the  second  to  the  fifth 
sacral  foramen  is  injected  with  20  cc.  of  a  i%  novocain-epine- 
phrin  solution.  No  injection  should  be  made  until  the  contact 
with  the  bone  is  felt.  The  needle  is  now  drawn  back  to  the  edge 
of  the  sacrum  and  is  directed  at  a  small  angle  toward  the  innomi- 
nate line,  always  pushing  it  parallel  to  the  median  plane.  In  this 
direction  the  needle  penetrates  deeper  than  before;  until  it  again 
strikes  the  bone  above  the  first  sacral  foramen  at  a  distance  of 


Surgical   Operations  -with  Local  Anesthesia  237 

9  to  10  cm.  from  the  point  of  entrance,  the  soft  parts  not  taken 
into  consideration ;  at  this  point  20  cc.  of  I  %  novocain-epinephrin 
solution  are  injected.  The  final  injection  of  5  cc.  of  the  solu- 
tion is  made  between  the  rectum  and  coccyx  from  the  same  point 
of  entrance.  A  similar  injection  is  made  on  the  opposite  side ; 
altogether  100  cc.  of  the  solution  is  required. 

I  have  had  better  success  aiming  to  surround  the  prostate 
directly  with  the  anesthetic  solution.  From  4  to  8  ounces  of  a 
5%  quinine  solution  are  introduced  into  the  bladder  as  a  pre- 
liminary. I  infiltrate  the  skin  with  i%  quinine  in  a  line  shaped 
like  an  inverted  U,  for  the  usual  perineal  incision  (Fig.  113). 
With  the  same  solution  I  inject  the  region  of  the  levator  high  up 
and  lateral  to  the  prostate,  using  about  15  cc.  on  each  side.  The 
immediate  neighborhood  of  the  prostate  (Fig.  114)  is  now  infil- 
trated with  a  i%  novocain-epinephrin  solution,  special  attention 
being  paid  to  the  region  about  the  urethra  in  front  of  the  prostate, 
and  to  the  periprostatic  connective  tissue.  The  parts  overlying  the 
prostate  are  now  incised  down  to  the  prostate  and  all  the  bleed- 
ing points  are  caught  up.  With  the  prostate  exposed  it  is  infil- 
trated on  all  sides,  along  the  urethra,  between  the  urethra  and 
bladder,  and  between  the  prostate  and  rectum,  and  into  the  pros- 
tate itself.  In  small  prostates  the  lateral  lobes  may  be  traversed 
and  the  bladder  wall  reached.  Hemostasis  is  now  secured,  the 
urethra  is  opened  and  the  bladder  explored.  The  retractor  may 
now  be  placed  into  position  and  the  enucleation  proceeded  with. 
This  is  facilitated  because  of  the  use  of  epinephrin.  The  degree 
of  traction  that  can  be  applied  varies,  but  traction  always  causes 
pain,  so  that  knife  and  scissors  must  be  used  for  enucleation  in 
preference  to  the  fingers.  Generally  the  operator  must  work  in 
a  deeper  cavity  than  when  using  general  anesthesia.  I  have  found 
a  special  retractor  to  facilitate  the  dissection.  After  enough  of 
the  prostate  has  been  cut  away  the  cavity  it  occupied  is  closed 
by  sutures. 

All  operations  above  described  place  a  heavy  tax  on  the  tech- 
nical skill  of  the  operator,  and  only  those  possessed  of  experience 


238  Surgical  Operations  with  Local  Ancstlicsia 


•'**" 


I'ig.  ll'i.     Sui>erficial  lines  of  infiltration  for  penneal  prostatectnomy  ;    x,  x,  x,  points  at  which 
the  needle  is  passed  in  making  the  deep  infiltrations. 


Surgical   Operations  witli   Local  Anesthesia 


239 


in  the  operations  under  general  anesthesia  of  this  region  will 
find  operations  under  local  anesthesia  satisfactory.  Even  then 
it  is  hard  work. 


-<Os  ischii 


Fig.  114.     Injection  of  the  periprostatic  tissue.  (Braun). 


CHAPTER  XX 
OPERATIONS  ON  THE  FEMALE  ORGANS 

The  cervix  and  perineum  present  a  wide  field  for  operation 
under  local  anesthesia.  In  fact,  no  pelvic  operation  is  beyond  its 
range.  From  the  patient's  standpoint  the  chief  objection  to  work 
on  these  parts  under  local  anesthesia  is  her  embarrassment  at 
being  placed  in  the  lithotomy  position.  This  is  best  overcome 
by  telling  the  patient  beforehand  that  the  position  is  the  worst 
feature  of  the  operation  and  that  every  precaution  will  be 
taken  to  guard  her  sensibilities.  If  she  has  been  provided  with 
leggings  and  is  kept  well  covered  with  a  sheet  while  the  legs  are 
being  fixed  into  the  stirrups,  her  embarrassment  will  soon  pass 
away.  Visitors  disagreeable  to  the  patient  should  be  excluded. 

The  position  is  at  best  uncomfortable  and  may  cause  pain, 
particularly  in  fat  women.  If  in  the  course  of  the  operation  the 
patient  shows  signs  of  restlessness,  it  is  more  likely  to  be  caused 
by  the  position  of  the  legs  than  by  the  manipulations  of  the 
operator.  Cramping  may  be  relieved  by  massage  or  by  raising 
or  lowering  the  standards.  The  foot  may  be  freed  from  th;- 
stirrup  and  the  leg  held  in  a  comfortable  position  bv  an  assistant. 

A  much  more  comfortable  position  is  attained  by  the  use  of 
holders  which  fit  the  popliteal  space  than  by  the  usual  foot  straps. 
The  comfort  is  further  enhanced  by  having  an  angle  (Fig.  115)  in 
the  standards  which  allows  the  leg  a  more  comfortable  position 
than  the  usual  perpendicular  standard.  This  position  brings  the 
legs  in  the  way  of  the  assistant,  but  this  inconvenience  is  more 
than  compensated  for  by  the  greater  comfort  of  the  patient. 

From  the  operator's  standpoint  the  most  difficult  problem  is 
the  prevention  of  traction  pain.  Traction  on  the  uterus  causes 
pain  from  tension  on  the  broad  ligaments.  Seizing  the  levaior 
muscles  may  cause  deep-seated  pain,  which  must  be  overcome 

240 


Surgical   Operations  ivith  Local  Anesthesia 


241 


by  infiltration  of  the  muscle  and  its  fascia.  Repair  of  the  cervix 
and  of  the  perineum  are  easily  accomplished  and  are  suitable 
operations  for  the  beginner.  Operations  such  as  hysterotomy  and 
the  Freund-Wertheim  fixation  require  considerable  skill.  Either 


Fig.  115.    Leg  holder  with  extended  offset  of  the  standard. 

quinine  or  novocain-epinephrin  may  be  used.    The  beginner  will 
find  the  latter  preferable  because  it  diminishes  bleeding. 

REPAIR  OF  THE  CERVIX. — The  cervix  is  supplied  by  sympathetic 
nerves  by  way  of  the  broad  ligaments.     It  is  not  very  sensitive, 


242  Surgical  Operations  with  Local  Anesthesia 

as  is  readily  demonstrated  by  the  common  practice  of  grasping 
it  with  tenaculum  forceps  when  making  office  examinations. 

The    cervix    is    exposed    by    a    suitable    perineal    retractor, 
fixed    with    a    tenaculum    and    drawn    down    as    near    as    pos- 
sible to  the  vulva.     The  needle  is  introduced  at  the  line  of  at 
tachment  of  the  vagina  to  the  cervix,  and  is  passed  obliquely 
upward   and    medially    so    as    to    enter   the   base    of    the   broad 


Fig.  116.    Direction  of  lines  of  infiltration  for  operations  on  the  cervix. 


ligament  and  penetrates  the  substance  of  the  uterine  muscle  just 
below  the  internal  os  (Fig.  116).  Several  cc.  are  injected  on 
each  side  of  the  cervix,  and  the  loose  tissue  between  the  cervix 
and  bladder  is  infiltrated  at  several  points.  The  vaginal  deflec- 
tion posterior  to  the  cervix  is  infiltrated  in  the  same  way.  If 
anesthesia  is  not  complete  an  additional  injection  directly  into 
the  angle  of  the  tear  may  be  made,  though  this  is  rarely  necessary. 


Surgical   Operations  with  Local  Anesthesia 


243 


A  wedge  of  tissue  corresponding  to  the  depth  of  the  tear  is 
then  removed  with  a  knife.  Enough  of  the  cervical  mucosa  is 
allowed  to  remain  to  insure  the  integrity  of  the  canal.  The  pri- 
mary suture  is  placed  at  the  upper  angle  of  the  incision,  care 
being  taken  that  it  include  all  of  the  freshened  surface  lest  a 
bleeding  vessel  escape  and  give  rise  to  embarrassing  hemorrhage 


Fig.  117.     Method  of  applying  figure  of  eight  suture. 

after  the  operation.  This  precaution  is  particularly  necessary 
when  the  parts  are  edematized  by  novocain-epinephrin.  The 
remainder  of  the  incision  is  then  closed  by  interrupted  sutures  in 
the  usual  manner  or  by  a  figure-of-8  suture  (Figs.  117  and  118). 
This  suture  is  more  quickly  placed  and  prevents  the  conical  point 
so  apt  to  form  after  interrupted  sutures  when  the  amount  of  tis- 
sue removed  has  been  large. 

DILATATION  AND  cuRETTAGE. — The  use  of  the  curet  is  not  nearly 
so   frequent  as   formerly  among  careful  surgeons,  and  it  is  to 


244 


Surgical  Operations  with  Local  Anesthesia 


be  regarded  as  fortunate  that  the  operation  is  not  readily  accom- 
plished by  the  tyro  under  local  anesthesia.  The  difficulty  lies  in 
the  density  of  the  uterine  muscle,  which  does  not  easily  permit 
diffusion  of  the  fluid  in  sufficient  quantity  to  reach  all  parts  in- 
cluding the  peritoneum.  In  the  recently  pregnant  uterus  this 
difficulty  does  not  obtain  (one  might  almost  say  unfortunately) 
and  curettage  may  be  readily  accomplished. 

Infiltration  should  begin  in  the  cervix  as  for  repair  of  lacera 


Fig.   118.     Figure  of  eight  suture  tied. 

tions  (Fig.  116),  using  care  to  inject  deeply  into  the  muscle  sub- 
stance. In  the  non-pregnant,  particularly  in  uteri  long  the  sub- 
ject of  chronic  inflammation,  a  special  syringe,  such  as  is  used  by 
dentists,  is  desirable.  In  the  recently  pregnant  uterus  satisfac- 
tory infiltration  may  be  secured  with  an  ordinary  syringe.  If  th<* 
operator  is  careful  to  ascertain  the  position  of  the  uterus  it  is 


Surgical   Operations  with  Local  Anesthesia  245 


easy  to  inject  the  body  of  the  uterus  through  the  base  of  the 
broad  ligament. 

If  after  dilatation  of  the  cervical  canal  the  endometrium  of  the 


Fig.  119.     Line  of  injection  of  the  cervix  and  in  the  interior  fold  together  with  the  incision. 

body  is  still  sensitive,  the  cavity  may  be  packed  for  five  minutes 
with  a  five  per  cent,  quinine  solution. 

HYSTEROTOMY. — When  there  is  something  within  the  uterus 
that  requires  removal,  splitting  the  uterus,  which  permits  an 
examination  by  sight  and  touch,  is  better  than  simple  dilatatioti 
and  curettage.  For  this  operation  the  anesthetic  is  injected  as  in 


246 


Surgical  Operations  with  Local  Anesthesia 


repair  of  the  cervix  and  the  tissue  between  the  bladder  and 
uterus  edematized.  The  bladder  is  then  lifted  from  the  cervix 
as  in  opening  the  pelvic  cavity  in  front  of  the  uterus  (Fig.  119). 
The  substance  of  the  cervix  is  then  injected  and  an  incision  is 
made  up  to  the  internal  os  (Fig.  120).  A  renewed  injection  is 


ig.   120.     Incision  in  the  cervix.     Line  of  infiltration  in  the  body  of  the  uterus, 
cross  indicates  the  point  for  deep  injection  in  the  lateral  wall  of  the  uterus. 


The 


then  made  through  the  wound  into  the  muscle  of  the  body,  and 
the  incision  is  continued  upward  as  high  as  necessary  to  permit 
an  examination  of  the  interior  of  the  uterus  (Fig.  121).  Any 
pathological  material  discovered  may  then  be  removed  after  first 
infiltrating  the  uterine  wall  about  it  (Fig.  121). 


Surgical   Operations  u'itli  Local  Anesthesia 


247 


Polypoid  hypertrophies  of  the  cndometrium  and  submucous 
fibroids  are  the  most  frequent  affections  requiring  treatment  by 
this  means.  The  area  of  the  uterine  wall  which  gave  rise  to 


Fig.  121.     The  uterus  is  split  to  the  fundus.     The  ring  of  infiltration  includes  the  base 

of  attachment  of  the  tumor.     The  interrupted  line  indicates  the  extent  ot 

uterine  wall  to  be  excised.     The  crosses  show  the  site  for  deep 

injection  into  the  cornua  when  those  regions 

requires  excision. 

these  lesions  would  better  be  excised  so  as  to  insure  against  a 
return  of  this  condition. 

After  the  lesion  has  been  excised  the  defect  remaining  is  re- 
paired with  chromic  gut  sutures.  The  incision  into  the  uterus  is 
then  closed  from  above  downward  so  as  to  terminate  below 


Surgical   Operations  with  Local  Anesthesia 


where  the  incision  began,  as  in  a  repair  of  the  cervix  (Figs.  121, 
123  and  124).  The  incision  into  the  uterine  fossa  is  then  re- 
paired by  uniting  the  vagina  to  the  cervix. 

This  operation  is  easily  performed  and  gives  complete  infor- 


Fig.  1£2.     Beginning  closure  of  the  uterine  incision  after  hysterotomy. 

mation  as  to  the  state  of  the  interior  of  the  uterus.  Before  un- 
dertaking it,  however,  the  operator  should  make  sure  that  the 
uterus  is  sufficiently  movable  to  permit  access  to  the  fundus,  if 
need  be. 

ANTERIOR    COLPORRIIAPHY. — Removal    of    redundant   portions 
of  the  anterior  vaginal  wall  is  easier  to  perform  under  novocain- 


Surgical   Operations  with  Local  Anesthesia 


249 


epinephrin  than  under  general  anesthesia,  because  of  the  lessened 
bleeding.  If  the  cervix  does  not  protrude  from  the  vulva,  the  in- 
filtration line  is  begun  half  an  inch  behind  the  meatus  (Fig.  125), 
and  extend  nearly  to  the  cervix  (Fig.  126).  From  this  primary 
lateral  lines  are  infiltrated  until  the  entire  tissue  between  the 
bladder  and  vagina  is  anesthetized.  If  the  cervix  comes  down 


Fig.  123.     Second  step  in  the  closure  of  a  hysterotomy  wound. 

into  the  vulva  readily,  the  infiltration  may  begin  at  the  cervix 
and  extend  nearly  to  the  meatus  (Fig.  126).  From  this  primary 
line  lateral  lines  are  infiltrated  as  before.  If  other  more  exten- 
sive operations  are  to  be  done  at  the  same  time  quinine  may  be 


250  Surgical  Operations  with  Local  Anesthesia 

used  for  this  part  of  the  operation,  or  very  dilute  solutions  of 
novocain-epinephrin.  In  either  event  an  unnecessarily  large 
amount  of  fluid  should  not  be  used  because  coaptation  of  tissue 
will  be  made  more  uncertain. 

The  operation  as  usually  done  may  then  proceed. 


Fit?.  124.     Hysterotomy  completed. 


REPAIR  OF  THE  PERINEUM. — When  repair  of  the  perineum  is  to 
follow  any  of  the  operations  above  described,  it  is  well  to  begin 
by  infiltrating  the  perineum.  By  so  doing  complete  anesthesia 
of  the  perineum  is  assured  by  the  time  the  cervical  or  other 


Surgical  Operations  zvith  Local  Anesthesia 


251 


operation  is  completed,  and  the  latter  is  facilitated  by  the  relaxa- 
tion of  the  perineum  so  induced. 

NERVE  SUPPLY  OF  THE  PERINEUM. — The  nerves  involved  in  the 


Fig.   125.     Infiltration  of  the  vaginal  wall  in  anterior  colporrhaphy. 

repair  of  the  perineum  are  the  same  as  those  involved  in  rectal 
operations.  These  nerves  may  be  blocked  before  their  exit 
from  the  canal  (Ilmer,  Zentralbl.  f.  Gynec.,  1910,  XXXIV,  699). 
by  passing  a  needle  at  the  posterior  border  of  the  tuber  ischii  in 


252 


Surgical  Operations  with  Local  Anesthesia 


a  direction  toward  the  foramen  ischii.  The  nerves  lie  under 
the  ligamentum  sacrotuberosum.  Sellheim  (Zentralbl.  f.  Gynec., 
1910,  XXXIV,  897)  prefers  to  reach  the  nerves  after  they  have 
divided  into  branches  by  infiltrating  the  pararectal  space. 


Fig    126.     Method  of  infiltrating  the  vaginal  wall  in  anterior  vaginal  colporrhaphy 
when  the  cervix  is  prolapsed. 


When  large  operations  are  to  be  done,  such  as  extensive  peri- 
neal  repair,  together  with  rectal  operations,  Ilmer's  technic  may 
be  used.  The  objection  to  it  is  its  uncertainty,  for  which  reason 
local  infiltration  is  usually  required  to  supplement  it.  Sacral 


Surgical  Operations  with  Local  Anesthesia  253 

blocking  is  more  efficient  in  extensive  operations.     The  nerves 
come  from  so  many  sources,  however,  that  in  most  cases  it  is 


Fig.  127      Infiltration  of  the  perineum  in  perineorrhaphy.       The  infiltration  begins  at 

the  point  marked  x.     The  needle  shows  the  point  of  injection  of  the  deeper 

tissues.     By  directing  the  needle  more  directly  backward  the 

levator  may  be  reached.      (Compare  fig.  114.) 

better  to  depend  upon  local  infiltration,  which  is  easily  done  in 
this  region. 

Infiltration  is  begun  at  the  middle  of  the  muco-cutaneous 
junction  (Fig.  127),  and  continued  along  it  to  the  caruncle  of 
each  side.  The  region  of  each  caruncle  is  then  grasped  by  a 


254  Surgical  Operations  with  Local  Anesthesia 

tenaculum  forceps.  When  moderate  traction  is  made  upon  these 
the  extent  of  the  laceration  becomes  exposed.  A  line  is  now 
infiltrated  from  the  point  of  beginning  to  the  highest  point  (Fig. 
128)  of  laceration,  taking  care  that  the  needle  is  not  pushed  into 


Fig.  128.     Lines  of  infiltration  of  the  tissue  of  the  recto-vaginal  septum. 

the  rectum.  The  entire  area  to  be  denuded  is  then  infiltrated  by 
a  liberal  injection  of  fluid  between  the  vaginal  and  rectal  walls. 
Either  anesthetic  may  be  used.  Novocain  gives  less  hemorrhage 
at  the  time  of  operation  and  is  advised  for  the  beginner. 


Surgical  Operations  ivith  Local  Anesthesia  255 


Inasmuch  as  the  chief  source  of  discomfort  is  the  pull  on  the 
levator  muscle,  infiltration  of  this  muscle  is  a  most  important 
point.  A  finger  in  the  vagina  will  locate  the  levator  and  deter- 


Fig.  129.     Vaginal  flap  raised  exposing  the  levators.     The  point  where  the  needle 
should  have  passed  in  making  the  deep  infiltration  is  indicated  by  x. 

mine  the  point  to  which  the  needle  should  be  thrust.  The  muscle 
itself  is  infiltrated  and  the  tissues  beyond  it,  both  at  the  level  at 
which  the  sutures  will  be  passed  and  anteriorly  toward  the  pubic 
bone.  These  tissues  are  sensitive  to  the  passage  of  the  needle, 


256  Surgical  Operations  tvith  Local  Anesthesia 


and  as  much  care  should  be  exercised  in  injecting  them  as  in 
infiltrating  the  skin. 

An  incision  can  then  be  made  along  the  line  of  the  first  infil- 


y*     'if-    \       i 


Fig.  130.     The  levator  muscle  is  hooked  up  by  the  needle. 

tration,  or  within  it,  wherever  the  operator  may  fancy.  The 
vaginal  flap  is  elevated  either  with  knife  or  scissors.  The  begin- 
ner may  even  be  permitted  to  push  the  vaginal  wall  loose  with  a 
bit  of  gauze.  The  levator  muscle  is  now  located  and  exposed 
with  knife  or  scissors  (Fig.  129). 


Surgical  Operations  u'ith  Local  Anesthesia  257 

The  muscle  is  lifted  up  on  the  tip  of  the  finger  and  the  suture 
passed  through  it  (Fig.  130).  Gentleness  in  this  manipulation  is 
advisable,  unless  the  operator  is  quite  sure  of  his  infiltration. 
The  opposite  side  is  hooked  up  in  a  like  manner  and  the  suture 
tied  (Fig.  131).  Additional  sutures  are  passed  in  the  same  way. 


Fig.   1H1.     The  opposite  levator  loop  is  hooked  up  and  the  sutures  tied. 

There  is  no  difficulty  of  securing  anesthesia  of  the  deep  peri- 
neal  fascia  and  this  layer  may  be  united  with  confidence  (Fig. 
132).  It  should  be  done  with  especial  care,  because  it  furnishes 
the  chief  support  of  the  parts  above. 


258 


Surgical  Operations  with  Local  AncstJicsia 


Every  operator  has  his  own  ideas  for  the  union  of  these  struc- 
tures and  any  whim  he  may  possess  need  not  be  restrained  be- 


Fig.  132.     Closure  of  the  perinea!  fascia. 

cause   he   is   operating   under   local   anesthesia.      The    foregoing 
technic  is  adopted  from  the  work  of  Howard  Hill. 

The  triangle  of  the  posterior  vaginal  wall  is  now  trimmed  off 
as  may  be  required,  and  a  running  suture  applied  to  the  entire 
extent  of  the  wound  remaining  (Fig.  133).  Care  must  be  exer- 


Surgical  Operations  with  Local  Anesthesia 


259 


cised  here  that  the  needle  does  not  sweep  beyond  the   region 
which  the  anesthetic  fluid  has  penetrated.     This  is  particularly 


Fig.   133.     The  skin  is  closed  in  a  line  parallel  with  the  axis  of  the  vagina. 

likely  to  take  place  near  the  sensitive  caruncles.     The  tendacula 
should  mark  the  limit  of  efficient  anesthesia. 

The  objection  raised  against  the  use  of  local  anesthesia  in 
plastic  work  that  it  interferes  with  healing,  applies  only  when  too 
much  fluid  is  employed.  Edematization  of  the  tissue  is  unneces- 


260  Surgical  Operations  with  Local  Anesthesia 

sary  and  harmful.  The  experienced  operator  will  repair  a  cer- 
vix and  perineum  with  the  use  of  less  than  an  ounce  of  solution, 
an  amount  which  produces  no  edema  and  interferes  in  no  way 
with  the  after-course  of  the  operation.  Twice  this  amount  of 
fluid  may  be  used  without  doing  harm.  If  the  operator  has  pro- 
duced edema  by  the  use  of  an  excessive  amount  of  fluid,  a  con- 
dition similar  to  that  present  after  labor  exists  and  may  be  met 
by  the  same  modification  in  technic — the  suture  must  be  drawn 
more  tightly  so  that  the  tissues  are  still  held  in  apposition  after 
the  fluid  is  absorbed.  Chromic  catgut  should  be  used  for  all 
sutures  except  the  one  for  the  vaginal  mucosa  where  plain  or 
pyoktanin  gut  is  preferable. 

OPERATIONS  ON  THE  VULVA. — Any  operation  on  the  vulva,  in- 
cluding tumors  and  incision  of  the  skin  for  pruritis,  may  be  per- 
formed with  infiltration  anesthesia.  Either  anesthetic  may  be 
employed ;  quinine,  if  the  operator  has  in  mind  the  after-comfort 
of  the  patient,  or  novocain-epinephrin,  if  he  has  in  mind  his  own 
convenience.  The  same  applies  to  operations  upon  the  urethra. 

THE  FREUND-WERTHEIM  OPERATION. — This  operation  is  begun 
as  for  exploratory  hysterotomy,  with  the  addition  that  the  ante- 
rior vaginal  wall  must  be  infiltrated  and  separated  as  for  anterior 
colporrhaphy.  Instead  of  splitting  the  uterus  after  the  vaginal 
wall  is  elevated  the  base  of  the  broad  ligaments  are  widely  infil- 
trated with  novocain-epinephrin.  The  uterine  wall  is  then  infil- 
trated before  an  attempt  is  made  to  pull  it  into  the  vaginal 
wound.  This  makes  it  insensitive  to  the  grasp  of  the  forceps  and 
to  the  subsequent  passage  of  the  sutures  when  it  is  fixed  in  the 
vagina.  As  the  uterus  is  exposed  and  drawn  into  the  wound, 
regions  higher  up  may  be  infiltrated. 

The  only  point  in  the  operation  presenting  any  difficulty  is 
the  pulling  of  the  uterus  into  the  vagina.  This  is  facilitated  by 
having  the  vaginal  wound  large  enough  to  permit  the  passage 
of  the  uterus  without  undue  traction.  For  this  reason  the  bol  1 
operator  will  have  less  difficulty  than  the  timid  one. 


Surgical  Operations  with  Local  Anesthesia  261 

Before  beginning  this  operation  the  surgeon  should  make  sure 
that  the  uterus  is  mobile.  A  uterus  may  be  low  in  the  pelvis  and 
yet  possess  attachments  that  will  make  the  operation  difficult. 

VAGINAL  HYSTERECTOMY. — Up  to  a  certain  point  this  opera- 
tion is  identical  with  hysterotomy.  The  base  of  the  broad  liga- 
ment is  infiltrated  more  widely  lateral  to  the  uterus  than  in  the 
operations  previously  described.  The  posterior  cul-de-sac  like- 
wise must  be  infiltrated. 

Whether  or  not  the  perineum  will  require  repair,  it  is  worth 
while  to  infiltrate  this  region  as  for  perineorrhaphy,  so  as  to 
secure  relaxation,  and  thereby  facilitate  very  much  the  removal 
of  the  uterus.  The  manner  in  which  the  uterus  is  removed  must 
be  planned  to  fit  the  individual  case.  If  the  uterus  is  freely 
mobile  ligation  may  begin  at  the  base  of  the  broad  ligament.  In 
more  difficult  cases  the  uterus  may  be  bisected  as  for  hysterotomy 
and  removed  in  pieces.  It  is  possible  to  remove  the  fundus, 
allowing  the  cervix  to  remain,  performing  in  this  way  a  supra- 
vaginal  amputation  per  vaginam. 

Hysterectomy  under  local  is  a  difficult  operation  at  best  and 
the  operator  must  be  skilled  before  he  undertakes  it. 

PALLIATIVE  OPERATIONS  FOR  CARCINOMA. — Extensive  infiltra- 
tion of  the  tissue  about  the  cervix  is  made  preferably  with  qui- 
nine. Several  ounces  may  be  deposited  about  the  affected  area 
without  much  regard  to  direction,  except  to  avoid  the  bladder 
and  rectum.  Any  palliative  procedure  may  then  be  employed, 
such  as  curettage  with  acetone  after  Gellhorn's  method,  or  the 
actual  cautery. 

Curative  operations  for  carcinoma  of  the  uterus  are  beyond 
the  realm  of  local  anesthesia.  It  is  worthy  of  note  that  in  manv 
cases  palliation  under  local  will  procure  a  greater  lease  of  life 
with  less  discomfort  to  the  patient  than  attempts  at  radical 
operation  under  ether.  This  point  is  not  sufficiently  appreciated. 

SHORTENING  OF  THE  ROUND  LIGAMENTS. — Any  of  the  methods 
commonly  employed  in  shortening  these  ligaments  may  be  done. 

ALEXANDER — ADAMS. — In  very  motile  uteri  without  descensus 


262  Surgical  Operations  zvith  Local  Anesthesia 

of  the  cervix  this  operation  gives  good  results.  The  technic  does 
not  differ  materially  from  that  described  for  the  anesthetization 
of  the  inguinal  canal  in  hernia.  The  absence  of  the  cord  and  her- 
nial  sac  make  care  in  injecting  the  canal  unnecessary.  The  liga- 
ments are  more  readily  found  than  under  general  anesthesia, 
because  of  the  bloodless  nature  of  the  field. 

THE  MONTGOMERY  or  any  other  intra-abdominal  method  that 
may  be  employed,  is  generally  to  be  preferred  to  the  operation 
just  described,  because  the  results  are  more  certain  and  the  time 
required  to  perform  it  is  less.  The  operation  I  prefer  is  a  trans 
verse  fascial  incision  with  the  fastening  of  the  ligaments  in  both 
ends  of  the  incision.  To  perform  this  operation  a  transverse 
line  is  infiltrated  in  the  superpubic  fold.  The  fascia  and  muscle 
of  the  abdominal  wall  are  infiltrated  through  this  line.  In  this 
way  the  entire  thickness  of  the  abdominal  wall  may  be  anesthe- 
tized. Should  anesthesia  be  imperfect,  the  fascia,  muscle  and 
preperitoneal  tissue  be  incompletely  anesthetized,  the  preliminary 
infiltration  may  be  supplemented  after  the  deeper  parts  are 
exposed. 

The  same  thing  may  be  accomplished  less  elegantly  by  making 
a  longitudinal  incision  into  the  abdomen. 

URETHRAL  CARUNCLE. — This  little  tumor  is  of  frequent  occur- 
rence, and  because  of  the  sensitive  nature  of  the  surrounding 
tissue,  the  operator  finds  an  interesting  field  for  the  exercise 
of  technical  skill.  The  simplest  method  of  anesthetizing  the  site 
of  the  tumor  and  the  distal  half  of  the  urethra  is  to  place  a  tab- 
let of  %  or  1/2  grain  of  cocain  or  two  grains  of  quinine  just  within 
the  urethral  orifice.  The  natural  moisture  of  the  parts  dissolves 
the  tablet  sufficiently  to  bathe  the  affected  area  in  a  concentrated 
solution  of  the  drug.  After  ten  minutes  complete  anesthesia 
will  have  taken  place  and  the  tumor  may  be  removed  and  its 
base  cauterized. 

Larger  tumors  in  this  region  may  be  removed  in  the  same  way. 
by  adding  to  the  anesthetization  above  described  an  infiltration  of 
the  surrounding  tissue  by  passing  the  needle  through  the  area 
previously  anesthetized  by  the  topical  application. 


Surgical  Operations  with  Local  Anesthesia  263 

SACRAL   BLOCKING   IN    PELVIC   SURGERY. — Ally   of    the    foregoing 

operations  may  be  done  under  sacral  blocking.  The  technic  of 
local  infiltration  above  described  has  the  advantage  over  sacral 
blocking,  however,  in  that  it  is  absolutely  certain  and  the  opera- 
tive field  is  practically  bloodless.  Sacral  anesthesia,  on  the  other 
hand,  occasionally  fails  in  part  and  must  be  supplemented  by 
local  injections.  This  is  particularly  liable  to  occur  in  the 
region  of  the  caruncles.  The  reason  for  this  failure  is  that  thi: 
region  receives  branches  from  the  ilio-inguinal  nerve  which  is 
unaffected  by  the  sacral  injection.  In  sacral  blocking  the  vessel 
constricting  effect  of  epinephrin  is  lost.  Rougher  handling  is 
possible  after  sacral  blocking.  This  is  particularly  true  in  dila- 
tation and  cttrettage. 


CHAPTER  XXI 
OPERATIONS  ABOUT  THE  RECTUM 

Operations  about  the  rectum  under  local  anesthesia  have  not 
been  popular  with  general  surgeons  but  have  found  favor  with 
patients.  Specialists  and  general  practitioners  have  been  more 
ready  to  recognize  the  merits  of  local  anesthesia  than  have  sur- 
geons. The  anal  region  is  on  the  whole  the  most  difficult  field 
for  the  employment  of  local  anesthesia.  Blocking  operations, 
because  of  the  abundant  nerve  supply  from  a  number  of  sources, 
is  difficult.  The  area  is  exceedingly  sensitive  and  the  position  of 
the  patient  during  the  operation  tends  to  make  the  technic  diffi- 
cult. Any  apprehensive  movement  on  the  part  of  the  patient 
adds  materially  to  the  difficulties  of  the  operator.  Nevertheless, 
when  the  fundamentals  are  mastered  no  other  region  permits 
operations  of  all  varieties  to  be  carried  out  with  more  satisfac- 
tory results  to  both  practitioner  and  patient.  No  other  class 
of  operations  deserves  more  to  be  done  under  local  anesthesia. 
Patients  are  reluctant  to  submit  to  general  anesthesia  for  the 
relief  of  a  condition  which  does  not  endanger  life  and  to  the 
inconvenience  of  which  they  have  by  degrees  learned  to  submit 
with  more  or  less  patience.  Only  when  actually  incapacitated  do 
they  readily  submit  to  radical  operations  under  general  anesthe- 
sia. The  result  of  reluctance  of  the  general  surgeon  to  employ 
local  anesthesia  has  been  to  drive  sufferers  from  piles  to  the  ad- 
vertiser, who  has  been  more  ready  to  accede  to  the  demand  for 
relief  without  general  anesthesia.  The  general  practitioner  can 
prevent  the  defection  of  his  patient  if  he  will  do  these  operations 
under  local  anesthesia.  Most  of  the  rectal  diseases  belong  to  the 
domain  of  minor  surgery  and  should  be  quite  within  the  province 
of  the  general  practitioner.  Certainly  any  man  who  can  repair 

264 


Surgical  Operations  with  Local  Anesthesia  265 

a  recently  lacerated  perineum  should  be  able  to  carry  out  nearly 
all  the  operations  upon  the  rectum  after  he  has  once  mastered  the 
rudiments  of  anesthesia  as  applied  to  this  region. 

ANATOMY. — A  knowledge  of  anatomy  is  a  necessary  prelimi- 
nary, and  that  not  alone  of  the  nerves  but  also  of  the  muscles 
and  vascular  supply,  for  nowhere  else  can  complications  affecting 
these  tissues  be  more  certainly  avoided  by  anticipating  them. 

Broadly  speaking  the  region  in  question  consists  of  the  termi- 
nation of  the  gut  canal,  the  group  of  muscles  surrounding  it  and 
the  associated  vessels  and  nerves.  The  external  sphincter,  an 
elliptical  muscle  surrounding  the  outlet,  is  the  most  important 
muscle.  Above  it  is  the  internal  sphincter,  which  is  merely  a 
reinforcement  of  the  circular  fibres  of  the  rectum.  The  integrity 
of  these  muscles  must  be  retained  lest  an  embarrassing  incon- 
tinence result.  Descending  from  above  in  the  submucous  layer 
are  the  hemorrhoidal  arteries  and  veins.  It  is  from  these  vessels 
that  post-operative  hemorrhage  may  occur  if  the  technic  has 
been  faulty.  The  vessels  which  approach  the  anal  region  through 
the  perirectal  space  are  readily  seen  during  the  operation  and  are 
as  readily  controlled.  The  nerve  supply,  for  the  most  part,  is 
chiefly  found  in  the  perirectal  space.  Appearing  from  either  side 
slightly  behind  the  anal  axis  are  the  long  perineal  nerves  and 
from  the  depth  supplying  the  lateral  and  anterior  portions  are 
the  hemorrhoidal  nerves.  The  coccygeal  nerve  approaches  from 
behind  (Fig.  134).  Descending  from  above  within  the  wall  of 
the  gut  are  branches  of  the  sympathetic  nerves.  These  like  sym- 
pathetic nerves  in  other  regions  of  the  intestinal  tract  are  sensi- 
tive to  traction.  None  of  these  structures  are  surgically  fastidious 
yet  they  demand  a  certain  respect  if  the  surgeon's  relations  in 
his  dealings  with  them  is  to  be  at  all  times  agreeable  and  har- 
monious. 

Operations  about  the  anus  may  be  divided  into  those  which  may 
be  done  without  dilatation  of  the  sphincter  and  those  in  which 
dilatation  is  a  necessary  preliminary.  In  the  former  class  are 
ischio-rectal  abscesses,  cutaneous  and  mixed  piles  and  palliative 


266 


Surgical  Operations  with  Local  Anesthesia 


operations  upon  prolapsed  internal  hemorrhoids.  Those  de- 
manding a  preliminary  dilatation  of  the  sphincter  are  internal 
hemorrhoids,  fistulas,  fissures  and  all  tumors  within  the  gut. 
Although  prolapsed  internal  piles  may  be  operated  without  dilata- 
tion, there  is  most  certain  to  be  some  that  have  remained  inter- 
nal to  the  sphincter  which  will  likely  give  rise  to  trouble  at  SOUK- 
future  date  and  a  recurrence  after  operation  is  likely  to  be  re- 


Fig.  134.     Nerves  about  the  rectum. 

corded  against  the  efficiency  of  the  surgical  treatment.  Therefore, 
even  if  one  pile  is  prolapsed  and  easily  within  reach  of  ligation 
without  dilatation,  the  sphincter  should  be  stretched  in  order 
that  all  hidden  nodules  may  be  reached.  Furthermore,  if  the 
prolapsed  pile  is  so  operated  the  pedicle  slips  back  within  the 
sphincter  and  should  hemorrhage  occur  it  is  almost  certain  to 
be  undetected  for  a  long  time. 


Snnjical  Operations  ivith  Local  Anesthesia  267 


DRUGS  EMPLOYED. — Novocain— epinephrin  gives  a  good  anesthe- 
sia and  the  skill  required  in  the  use  of  this  drug  is  but  little,  but 
the  after-pain  is  prolonged  and  intense.  For  this  reason  I  use 
this  drug  only  for  sacral  blocking  in  extensive  operations  about 
the  anus.  Quinine,  on  the  other  hand,  requires  more  skill  in 
its  use,  but  the  prolonged  relief  from  after-pain  makes  the 


Fig.   135.     Infiltration  over  surface  of  cutaneous  hemorrhoid. 

use  of  this  drug  imperative.  Novocain  may  be  used  for  para- 
rectal  injection,  but  in  the  region  affected  by  cutting  and  liga- 
tion  the  use  of  quinine  is  imperative. 

EXTERNAL  HEMORRHOIDS. — This  variety  is  formed  by  the  co- 
agulation of  blood  within  the  veins  of  the  anal  region.  They  are 
covered  by  skin  not  materially  changed,  or  at  most  but  slightly 
inflamed.  When  the  thrombosis  extends  into  the  veins  of  the 
mucous  surface,  a  mixed  variety,  the  mucocutaneous  variety  is 


268  Surgical  Operations  with  Local  Anesthesia 


obtained.     If  the  submucous  veins  are  extensively  involved  a 
prolapsed  internal  pile  may  be  diagnosticated. 

If  the  tumor  is  confined  to  the  cutaneous  surface  and  the  skin 
over  it  is  but  slightly  or  not  at  all  involved,  a  line  may  be  infil- 
trated over  its  surface  (Fig.  135).  A  simple  incision  is  made  into 
its  substance  and  the  clot  turned  out.  A  suture  may  be  placed 


Fig.   130.     Inflamed  mucocutaneous  pile  showing  line  of  infiltration  in  the  normal 
skin  about  the  tumor. 

to  control  the  bleeding ;  this  may  be  removed  after  a  day  or  two 
and  healing  by  granulation  permitted.  In  some  instances  the 
mere  compression  by  a  tampon  for  a  few  minutes  controls  the 
bleeding  and  a  suture  is  not  necessary. 

If  the  skin  over  the  pile  is  much  inflamed  or  if  the  thrombus 
extends  into  the  mucous  membrane  it  is  better  to  infiltrate  the 
normal  skin  about  the  tumor  (Fig.  136),  circumscribing  the  pain- 
ful area.  Deep  injections  beneath  the  tumor  are  also  necessary. 


Surgical  Operations  with  Local  Anesthesia 


269 


Incision  may  then  be  made  into  the  mass  and  the  clots  turned 
out ;  or,  better  still,  a  flap  of  skin  and  mucous  membrane  may  be 
raised  up,  and  the  venous  mass  ligated  and  dissected  out.  The 
edges  of  the  flap  may  then  be  approximated  by  a  few  sutures. 
Infiltration  of  the  mucous  surface  may  be  painful  and  the  com- 
fort of  the  patient  is  much  enhanced  by  a  previous  topical  appli- 
cation of  cocain  or  novocain  in  2  per  cent,  solution,  or  quinine 


Fig.  137.     Prolapsed  internal  hemorrhoid.     The  skin  has  been  infiltrated  as  in  fig.  136 
and  the  base  of  the  pile  is  being  infiltrated. 

in  10  per  cent,  solution.  Water  as  hot  as  can  be  borne  for  a  few 
minutes  likewise  makes  manipulation  less  painful.  These  ad- 
ditional attentions  to  the  patient's  comfort  are  quite  well  worth 
the  time  expended,  particularly  to  the  operator  of  limited  ex- 
perience. 

For  prolapsed  internal  hemorrhoids,  the  cutaneous  border  is 
infiltrated  as  above ;  and  infiltration  of  the  base  of  the  tumor 
either  with  or  without  preliminary  topical  anesthetization  (Fig. 


2/o  Surgical  Operations  ivith  Local  Anesthesia 

138)  is  sufficient  to  permit  painless  transfixion  and  ligation  of  the 
piles.  The  undesirability  of  removing  the  prolapsed  pile  alone 
has  been  sufficiently  emphasized;  but  in  many  instances  the  prac- 
titioner and  patient  are  satisfied  with  the  relief  the  removal  of 
the  chief  offender  affords  and  are  willing  to  risk  the  mischief 
its  }ess  conspicuous  fellows  may  produce  at  a  later  date. 

OPERATIONS    WITH    DILATATION    OF    THE    SPHINCTER INTERNAL 


Fig.  138.     A  line  ,of  skin  is  infiltrated  about  the  anal  margin  over  the  anal  sphincter. 

HEMORRHOIDS. — Operations  demanding  a  preliminary  dilatation 
of  the  sphincter  may  well  be  divided  into  two  steps,  the  dilata- 
tion and  the  operation  itself. 

INTERNAL  HEMORRHOIDS. — Operations  demanding  a  prelimi- 
nary dilatation  of  the  sphincter  may  well  be  divided  into  two 
steps,  the  dilatation  and  the  operation  itself. 

In  order  to  dilate  the  sphincter  it  must  be  anesthetized  and  to 
reach  the  sphincter  the  skin  must  first  be  anesthetized.  This  is 


Surgical  Operations  with  Local  Anesthesia  27 1 

most  conveniently  done  by  infiltrating  a  circle  about  the  anal 
margin  (Fig.  138).  Beginning  at  the  most  convenient  point  Over 
the  coccyx  a  semi-circle  is  described  on  one  side  and  then  begin- 
ning at  the  original  point  the  opposite  side  is  infiltrated,  the  two 


Fig.   l.'{9.     The  needle  is  shown  passed  to  the  proper  depth 
to  infiltrate  the  sphincter. 

lines  meeting  in  the  raphe  in  front  of  the  anus.  A  needle  is  now 
thrust  into  the  substance  of  the  sphincter  at  the  four  points 
marked  in  Fig.  138.  A  needle  of  sufficient  length  to  make  sure 
of  penetrating  the  muscle  must  be  employed  (Fig.  139).  A  fin- 
ger introduced  within  the  anus  will  assist  in  guiding  the  needle 


2/2 


Surgical  Operations  with  Local  Anesthesia 


to  the  proper  depth  in  order  to  infiltrate  the  sphincter  (Fig.  140). 
The  mucous  membrane  of  the  anus  may  be  anesthetized  by  plac- 
ing a  small  pledget  saturated  with  a  10%  solution  of  quinine  or 
a  4%  cocain  solution  within  the  grasp  of  the  sphincter.  By  the 
time  the  skin  about  the  anus  has  been  infiltrated  the  finger  may 
be  introduced  painlessly.  I  ordinarily  omit  this  procedure,  for 


Fig.  140.     The  finger  within  the  anus  determines  the  depth  of  the  needle. 
(Redrawn  from  Braun). 


usually  the  infiltration  of  the  shincter  permits  the  finger  to  be 
introduced  without  pain  if  it  is  done  gently ;  and  after  the  sphinc- 
ter is  infiltrated  the  mucosa  may  be  injected  from  within  the  anal 
margin.  The  process  of  dilatation  is  facilitated  by  a  special  peri- 
neural  blocking  of  the  coccygeal  nerves  by  depositing  a  syringe 
full  of  fluid  immediately  in  front  of  the  tip  of  the  coccyx. 

The  dilatation  of  the  sphincter  may  now  be  commenced.  The 
index  finger  is  placed  well  within  the  sphincter  and  is  followed 
by  the  same  corresponding  finger  of  the  opposite  hand.  Trac- 
tion is  now  applied  until  the  desired  degree  of  dilatation  is  se- 
cured. If  the  muscle  is  properly  infiltrated  but  little  traction  is 
required  in  order  to  secure  the  needed  dilatation,  since  the  anes- 
thetized muscle  loses  its  power  to  contract.  This  relaxation 
comes  more  readily  with  novocain-epinephrin,  but  the  after-pain 


Surgical  Operations  with  Local  Anesthesia  27  j 

is  greater.  It  is  worth  while  to  take  plenty  of  time  in  making 
the  dilatation,  because  permanent  relaxation  is  less  likely  to  occur 
when  done  in  this  manner  than  when  the  dilatation  is  done 
bruskly.  Pain  from  dilatation  is  usually  due  to  the  failure  to 
properly  inject  the  deeper  layers  of  the  sphincter.  When  the 
sphincter  is  dilated  the  pile  nodules  are  sought  and  fixed  with 


Fig.  141.     Traction  is  made  upon  the  pile  and  injection  is 
made  directly   into  the  pedicle. 

forceps.  Not  infrequently  traction  on  the  pile  causes  pain,  due 
to  stretching  the  sympathetic  filaments  coming  down  from  above. 
This  may  be  readily  controlled  by  the  injection  of  the  pedicle 
above  the  proposed  site  of  ligation  (Fig.  141).  The  operation  may 
now  proceed  in  the  usual  manner.  The  method  I  prefer  is  liga- 
tion performed  by  passing  a  threaded  needle  eye-end  first 
through  the  pedicle  (Fig.  142).  The  ligature  is  tied  without  first 
incising  the  mucous  surface  as  usually  recommended.  The  larger 


274 


Surgical  Operations  with  Local  Anesthesia 


vessels  descend  from  above  and  are  effectually  controlled  by  this 
method.  The  redundant  portion  may  then  be  excised  and  the 
edges  of  the  mucosa  united  by  sutures.  The  usual  method  of 
forming  a  pedicle  is  to  incise  the  mucosa  above  and  doubly  ligate 
the  pedicle  so  formed.  In  many  recent  cases  the  mucosa  may  be 
elevated,  the  pile  isolated  and  the  pedicle  ligated  and  the  flap 
replaced  and  united  with  sutures.  The  number  of  masses  which 
require  ligation  varies.  Usually  one  on  each  side  slightly  behind 


Fig.  142.     The  needle  is  passed  eye  end  first  through  the  pedicle. 

the  center  and  one  anterior  corresponding  to  the  site  of  chief 
blood  supply,  will  be  sufficient.  As  few  pile  masses  as  possible 
should  be  ligated  in  order  to  lessen  the  liability  to  stricture. 

If  tags  of  skin  remain  they  may  be  excised  and  the  edges 
loosely  approximated  with  fine  catgut. 

The  cautery  may  be  employed,  but  care  must  be  exercised  lest 
the  heated  instrument  come  too  close  to  the  thigh  or  the  buttock. 
The  hissing  sound  produced  by  the  cautery  is  apt  to  produce  a 


Surgical  Operations  •with  Local  Anesthesia  275 

disquieting  effect  upon  the  patient  and  the  transmitted  warmth 
to  unanesthetized  areas  is  apt  to  excite  unpleasantly  his  appre- 
hension. 

There  is  no  after  treatment.  Quinine  properly  employed  gives 
anesthesia  which  lasts  for  several  days  or  until  healing  is  well 
established.  The  skill  exercised  in  making  the  infiltration  and 
in  dilating  the  sphincter  determines  the  after  course.  If  the 
amount  of  fluid  is  excessive  and  a  large  amount  of  exudate  is 
produced  a  sense  of  fullness  may  be  felt  in  the  rectum.  This 
may  be  so  great  in  some  instances  as  to  interfere  with  a  free 
movement  of  the  bowels,  according  to  the  patient's  view.  This 
is  only  temporary  and  disappears  in  a  week  or  two,  always  re- 
sulting in  perfect  resolution.  The  patient's  mind  is  set  at  ease 
if  this  result  is  explained  to  him. 

FISTULA  IN  AND. — The  radical  cure  of  anal  fistula  can  be  ac- 
complished with  surprising  ease  under  local  anesthesia.  MY 
own  preference  is  for  an  excision  of  the  fistula  with  the  imme- 
diate closure  of  the  fistulous  tract.  Many  still  prefer  the  simple 
incision  and  for  the  beginner  this  is  certainly  the  operation  of 
election. 

INCISION  OF  THE  FISTULOUS  TRACT. — This  operation  merely 
aims  at  conversion  of  the  fistu'a  into  an  open  wound  which  shall 
be  allowed  to  heal  by  granulation.  If  the  internal  opening  is 
within  the  sphincter  the  operation  may  be  done  without  a  pre- 
liminary stretching  of  that  muscle.  If  it  ends  high  within  the 
gut  the  sphincter  must  be  dilated. 

The  skin  about  the  opening  (Fig.  143)  and  a  line  from  this 
point  to  the  anal  margin  and  up  the  mucous  surface  to  the  open- 
ing of  the  tract  within  the  gut  are  infiltrated.  Injections  are 
then  made  in  the  deeper  portions  along  the  line  of  the  fistula  and 
anal  sphincter,  and  then  in  the  tissue  about  the  fistula. 

Because  of  the  scar  tissue  present  infiltration  must  be  made 
with  unusual  care.  The  scar  tissue  itself  cannot  be  injected  and 
must  in  consequence  be  blocked  off  by  infiltrating  the  tissue  about 


276 


Surgical  Operations  with  Local  Anesthesia 


it  (Fig.  144).  The  scar  tissue  is  sometimes  very  extensive,  par- 
ticularly if  the  patient  has  previously  been  treated  by  incison 
or  by  the  injection  of  irritating  fluids. 

In  extensive  involvement  of  this  region  by  fistulous  tracts  it  is 
advantageous  to  make  a  sacral  blocking  with  novocain  and  use 
quinine  in  the  field  of  operation  wherever  it  is  needed  to  supple- 
ment the  sacral  blocking  and  for  the  purpose  of  controlling  after- 
pain. 


Fig.  14-S.     Line  of  infiltration  in  the  skin  for  fistula  in  ano. 

An  incision  is  then  made  down  to  the  director  within  the  tract. 
Should  the  tract  lead  beyond  the  external  sphincter  the  opera- 
tion must  be  interrupted  in  order  to  infiltrate  the  deeper  portions 
of  the  gut.  Bleeding  points  should  be  picked  up  and  ligated.  A 
tampon  should  not  be  depended  upon  to  control  the  bleeding. 
The  bottom  of  the  tract  should  be  incised  to  permit  new  granu- 
lations to  develop ;  the  wound  is  loosely  packed  with  gauze  and 
allowed  to  granulate.  This  operation  gives  good  results  in  sim- 
ple straight  fistulas  though  from  4  to  8  weeks  are  required  for 
healing  to  take  place. 


Surgical  Operations  with  Local  Anesthesia  277 

EXCISION  OF  THE  FisxuLous  TRACT. — The  operation  of  choice 
in  anal  fistula  is  the  excision  of  the  tract  or  tracts  and  the  imme- 
diate suture  of  the  wound.  It  is  true  the  method  sometimes  fails, 
but  results  will  be  secured  in  90  per  cent,  of  cases  and  should  in- 


Fig.  114.     The  tissue  about  the  fistula  is  infiltrated  throughout  its  length. 

fection  take  place  healing  by  granulation  follows  and  nothing  has 
been  lost.  If  successful,  healing  is  complete  in  a  week  or  two 
as  after  the  repair  of  a  lacerated  perineum. 

If  the  tract  is  high  or  complicated  the  sphincter  should  first 
be  dilated  as  already  described.  The  fistulous  tract  is  then  infil- 
trated as  for  the  simple  operation  by  incision.  A  grooved  direc- 


278  Surgical  Operations  with  Local  Anesthesia 

tor  is  passed  through  the  tract  and  the  fistulous  tract  dissected 
out  using  the  director  as  a  guide  (Fig.  145).  The  tract  should 
be  removed  as  an  intact  tube.  If  inadvertently  cut  into  infection 
will  be  invited.  It  may  be  well  to  inject  the  tract  with  tincture 
of  iodine  before  the  operation  is  begun  if  the  operator  is  not 
sure  of  his  skill  in  removing  it  intact.  If  the  opening  in  the  gut 


Fig.  14o.     The  fistulous  tract  is  dissected  out  intact. 

is  high  up  the  cut  edges  of  the  gut  must  be  grasped  lest  they  slip 
beyond  reach  and  bleeding  points  cause  embarrassment. 

The  tract  being  removed  and  all  accessory  tracts  attended  to 
in  a  like  manner,  closure  of  the  wound  is  begun  by  suturing  first 
the  incision  in  the  gut.  Interrupted  sutures  of  catgut  are  used 
and  as  the  gut  is  closed  it  is  allowed  to  retract  into  its  normal 
position.  The  deeper  portion  of  the  wound  is  closed  by  buried 
catgut  sutures  (Fig.  146),  after  which  silkworm  sutures  are  used 
to  close  the  skin  (Fig.  147). 

The  rectum  is  lightly  packed  with  gauze  to  protect  the  line  of 
suture  as  much  as  possible.  The  bowels  are  kept  locked  with 
opium  for  four  days  and  are  then  moved  by  a  combined  laxative 
and  enema. 


ical  Operations  ivith  Local  Anesthesia  279 


Fig.  146.     Buried  sutures  of  catgut  placed  through  the  severed  ends 
of  the  external  sphincter. 


Fig.  147.     Deep  silkworm  sutures  close  the  skin      Catgut  in  the  lumen  of  the  bowel. 


280  Surgical  Operations  with  Local  Anesthcsir 

A  number  of  difficulties  may  be  encountered  in  this  operation. 
The  accessory  tracts  may  be  difficult  to  find.  Usually  they  ex- 
tend about  the  anus  horseshoe-fashion  between  the  sphincter 
and  skin.  If  the  internal  opening  cannot  be  found  great  care 
must  be  exercised  to  find  the  highest  point  of  the  tract  before 
opening  is  made  into  the  gut.  When  accessory  sinuses  are  pres- 
ent it  may  be  necessary  to  stop  the  operation  to  permit  renewal 
of  the  infiltration.  There  may  be  a  temptation  for  the  operator  to 
abbreviate  the  operation  if  the  sinus  goes  beyond  his  primary 
estimate  of  the  extent  of  the  disease.  It  is  better,  therefore,  if 
the  extent  of  the  disease  is  not  clearly  discernible  before  the 
operation  to  make  a  sacral  blocking  at  the  beginning. 

FISSURES  OF  THE  ANUS. — In  very  small  fissures  a  simple  injec- 
tion of  the  anesthetic  about  its  base  permits  of  excision.  In  the 
larger  and  more  complicated  it  is  better  to  do  a  typical  opera- 
tion, which  requires  the  dilatation  of  the  sphincter  as  advised 
for  the  removal  of  hemorrhoids.  The  affected  area  may  then 
be  excised  and  the  defect  closed  by  suture.  Quinine  is  the  anes- 
thetic of  choice  because  of  the  very  intense  after-pain  when 
more  ephemeral  anesthetics  are  used. 

CARCINOMAS  OF  THE  RECTUM. — Carcinomas  situated  low  in  the 
rectum,  that  is,  when  their  upper  border  can  be  well  circum- 
scribed by  rectal  palpation,  are  easily  removed  under  local  anes- 
thesia. Those  situated  higher  up  cannot  be  so  removed  because 
the  necessary  traction  will  cause  pain  in  the  upper  part  of  the 
sigmoid.  In  such  cases  it  is  best  to  loosen  the  rectum  and  as 
much  of  the  growth  as  is  accessible  from  below  under  local 
anesthesia,  and  then  to  finish  the  operation  under  ether,  either 
from  below  or  by  the  abdominal  route.  This  plan  reduces  very 
materially  the  duration  of  the  general  anesthetic. 

The  first  part  of  the  infiltration  for  carcinoma  is  done  in  the 
same  way  as  for  the  removal  of  hemorrhoids,  preferably  with 
quinine.  After  this  has  been  done  the  tissues  higher  up  are 
infiltrated.  The  insertion  of  the  levator  is  the  essential  area 
requiring  infiltration  and  in  the  male  the  tissue  between  the 


Surgical  Operations  with  Local  Anesthesia  281 

rectum  and  prostate.  For  this  part  novocain-epinephrin  is  pre- 
ferable. It  is  not  difficult  to  infiltrate  the  perirectal  tissue  if  the 
needle  is  long  enough  to  reach  the  sensitive  area.  A  needle  at 
least  four  inches  long  is  required.  The  finger  in  the  rectum  gives 
the  operator  a  definite  notion  of  the  presence  of  the  point  of  the 
needle.  It  is  possible  in  this  way  to  anesthetize  the  pararectal 
tissue  as  high  as  the  promontory. 

The  rectum  is  circumscribed  either  removing  the  sphincters 
or  leaving  them,  depending  upon  the  situation  of  the  carcinoma. 
The  levator  is  then  encountered  and  should  sensitiveness  re- 
main it  may  be  infiltrated  anew.  With  experience  this  necessity 
will  not  arise.  If  gentle  traction  is  exercised  after  the  levator 
has  been  cut  it  will  bring  the  mesentery  into  view,  and  if  this  is 
cut  high  up  it  is  possible  to  bring  down  tumors  situated  quite 
high.  When  the  tumor  has  been  delivered  out  of  the  perineal 
wound  it  may  be  excised  without  fear  of  causing  the  patient 
pain. 

In  high  carcinomas  it  has  been  my  practice  to  loosen  the  gut 
from  below  as  high  as  the  promontory  under  local  anesthesia, 
and  follow  this  by  amputation  through  an  abdominal  incision 
with  the  establishment  of  a  permanent  inguinal  fistula.  This  has 
given  more  satisfactory  results  than  sacral  resection. 


CHAPTER  XXII. 
OPERATIONS  ON  THE  EXTREMITIES 

The  subject  of  minor  operations  on  the  extremities  under 
local  anesthesia  is  of  the  greatest  importance  to  the  general  prac- 
titioner, because  most  of  his  work  will  lie  in  this  region.  The 
parts  are  very  sensitive  and  the  possible  lesions  manifold,  so 
that  he  must  use  the  greatest  care  in  the  choice  of  methods  and 
in  their  execution.  Larger  operations  under  local  anesthesia 
have  not  met  with  uniform  success,  and  their  general  employment 
is  not  at  the  present  time  advisable.  The  general  principles 
concerning  them  are  presented  here  because  they  are  occasion- 
ally of  great  service  and  because  it  is  desirable  that  they  be 
developed  further.  Some  of  the  procedures  used  for  these  larger 
operations  are :  injections  into  joint  cavities  for  dislocations ; 
infiltration  about  fractured  bones ;  blocking  of  larger  nerve 
trunks  near  their  origin,  and  especially  brachial  plexus  anes- 
thesia, and  blocking  of  the  sciatic  and  anterior  crural  nerves. 

INFECTIONS  OF  THE  EXTREMITIES. — Localized  infections  may 
be  anesthetized  by  circumscribing  the  inflamed  area  with  a  novo- 
cain-epinephrin  solution.  Very  gentle  pressure  should  be  exerted 
for  sudden  increase  in  the  tissue  tension  causes  acute  pain. 
In  opening  subcutaneous  abscesses,  where  the  skin  is  not  directly 
affected,  the  line  of  incision  may  be  injected  directly,  beginning  in 
the  healthy  skin  on  one  side  of  the  lesion.  Subfascial  inflamma- 
tions require  deeper  injections  about  the  affected  area.  For  the 
more  serious  infections  about  tendon  sheaths  and  in  the  sub- 
fascial  tissue  local  anesthesia  should  not  be  used  indiscriminately. 
In  such  cases  the  extent  of  the  disease  often  cannot  be  ascer- 
tained exactly  before  operation,  and,  at  best,  anesthesia  in  in- 
flamed tissue  is  difficult  to  obtain.  Furthermore,  patients  suf- 
fering from  such  infections  are  usually  irritable,  because  of  pre- 
282 


Surgical  Operations  ivith  Local  Anesthesia  283 

vious  suffering.  In  all  deep  and  extensive  infections  nitrous 
oxide  gas  is  by  all  odds  the  anesthetic  of  choice.  Only  when 
gas  is  not  obtainable,  and  when  the  patient  has  a  special  con- 
traindication against  ether  should  plexus  anesthesia  and  nerve 
blocking  of  the  large  trunks  be  undertaken  in  deep  infection  of 
the  extremities.  When  patients  have  pus-smeared  extremities 
one  should  hesitate  to  make  deep  injections  in  the  proximal 
parts. 

FRACTURES  AND  DISLOCATIONS. — An  American,  Conway  (N.  Y. 
Mcd.  Jour.,  1885,  II,  832),  was  the  first  to  employ  local  anesthe- 
sia in  fractures  and  dislocations. 

The  difficulty  encountered  in  the  reduction  of  fractures  is  due 
to  the  muscular  spasm  produced  reflexly  by  the  injured  tissues. 
When  the  damaged  area  is  anesthetized  the  spasm  subsides,  but 
may  return  as  the  anesthesia  disappears.  This  fact  must  be  kept 
in  mind  in  placing  splints,  for  apparatus  which  holds  the  frac- 
tured ends  in  place  during  the  anesthesia  may  be  inadequate  after 
the  anesthesia  disappears.  This  applies  particularly  to  fractures 
of  the  humerus.  In  most  cases,  however,  fractures  which  are 
properly  reduced  and  splinted  remain  reduced. 

The  first  advantage  of  local  anesthesia  in  the  reduction  of  frac- 
tures is  that  the  patient  is  saved  the  unpleasantness  of  ether. 
Further,  unlimited  time  is  allowed  for  the  reduction  of  the  frac- 
ture and  with  the  same  anesthesia  the  splint  may  be  applied, 
examination  under  x-rays  undertaken  and  the  splint  reapplied 
if  necessary.  The  dangerous  excitability  of  the  etherized  patient 
is  avoided  and  the  bandage  is  more  easily  applied.  The  great 
disadvantage  lies  in  the  injection  itself,  not  because  it  is  danger- 
ous when  ordinary  care  is  used,  but  because  the  complications 
which  are  so  numerous  in  fractures  and  dislocations  may  be  attri- 
buted to  the  injection.  Until  the  method  is  more  commonly 
used  the  general  practitioner  will  be  playing  on  the  side  of  safety 
to  call  in  a  colleague  and  make  the  reducton  under  ether.  In 
fractures  in  which  the  skin  has  been  bruised  the  needle  should 
pass  through  uninjured  skin,  and  if  the  injury  to  the  surrounding 


284 


Surgical  Operations  with  Local  Anesthesia 


soft  parts  has  been  considerable  the  case  should  be  considered 
unsuitable  for  local  anesthesia. 

From  studies  upon  animals  the  following  is  deduced :  in  re- 
cent fractures  the  use  of  novocain-epinephrin  solution  will  limit 
hemorrhage  and  exudation  into  the  region  of  the  injury  and 
in  so  doing  may  limit  the  plastic  material  needed  for  repair. 
Quinine  is  unsuitable  in  fractures  because  of  the  excessive  ex- 
udate  of  granular  fibrin  which  interferes  with  the  early  pro- 
cesses of  repair.  , 


Fig.  148.     Method  of  infiltration  about  the  ends  of  bones  in  fracture. 


The  technic  is  simple.  The  skin  is  sterilized  with  iodine  and 
a  solution  of  novocain-epinephrin,  %%  is  injected  about  the 
ends  of  the  fractured  bone.  If  there  is  displacement  of  frag- 
ments each  fragment  must  be  circumscribed  with  fluid.  It  is 
preferable  to  make  the  injection  from  two  points  diametrically 
opposite  (Fig.  148)  in  order  that  the  periosteum  may  be  reached 
at  all  points.  Thirty  or  more  cubic  centimeters  are  required. 
About  20  minutes  is  required  for  complete  anesthesia  to  take 
place. 


Surgical  Operations  zvith  Local  Anesthesia 


285 


In  dislocations  injection  is  made  directly  into  the  joint  cavity 
from  the  most  convenient  point.  In  hip  dislocations  Braun 
makes  injections  about  the  dislocated  head  and  into  the  acetabu- 
lum  by  introducing  the  needle  external  to  the  anterior  superior 
spine  and  following  the  bone  into  the  acetabulum.  In  the 
knee  Deutschlander  (Zentralbl.  P.  Chir.,  1913,  XL,  377) 
injects  y2c/c  solution  on  each  side  of  the  ligamentum  pa- 


Fig.  149.     Injection  of  the  left  knee  joint,    a.  Injection  of  the  posterior  recess; 
b,  subpatellar  injection. 

tellae,  injecting  each  half  separately.  The  infrapatellar  reg- 
ion, the  region  of  the  crucial  ligaments  and  the  posterior 
recesses  then  receive  attention  (a,  Fig.  149).  The  needle  is 
withdrawn  so  that  the  point  just  remains  within  the  joint 
cavity  and  is  then  passed  upward  under  or  to  the  side  of 
the  patella  into  the  suprapatellar  portion  of  the  capsule 
(b,  Fig.  149).  After  10  or  20  minutes  reduction  may  be  accom- 
plished. Pays  used  80  to  100  cc.  with  the  express  purpose 
of  distending  the  capsule  in  order  to  mechanically  facilitate 
reduction. 


286 


Surgical  Operations  with  Local  Anesthesia 


Deutschlander  warmly  recommends  joint  injections  for  the 
manipulation  of  fixed  joints  and  for  operations.  He  regards 
a  bloodless  field  as  essential  and  employs  the  same  technic  to 
secure  this  as  is  recommended  for  Bier's  venous  anesthesia.  My 
experience  has  been  that  the  constriction  required  to  secure  the 
necessary  anemia  is  intolerably  painful  to  the  patient.  Intra- 


Fig.  150.     Injections  about  finger  into  region  of  digital  nerves. 

capsular  injections  are  not  effective  in  adherent  joints  when 
there  are  extensive  adhesions  within  or  about  the  joint,  but  in 
recent  adhesions  gentle  manipulation  continued  over  a  prolonged 
period  is  possible. 

My  own  practice  is  to  limit  intracapsular  injections  to  cases 
in  which  injections  of  formalin-glycerine  are  to  be  used.  I 
aspirate  the  joint  if  it  contains  fluid,  and  inject  5%  quinine  solu- 
tion. I  allow  this  to  remain  20  minutes,  withdraw  it  and  then 


Surgical  Operations  with  Local  Anesthesia 


287 


inject  formalin-glycerine  after  Murphy's  method.  The  quinine 
produces  a  considerable  degree  of  anesthesia,  and  in  gonorrheal 
arthritis  the  quinine  may  have  some  effect  on  the  disease  itself. 
I  have  used  quinine  injections  directly  into  the  joint  for  the  re- 


Fig.  151.     Ring  line  indicates  the  skin  infiltration.     The  needles  show  direction 
of  blocking  the  nerve  trunks. 

lief  of  pain  in  gonorrheal  joints,  and  in  those  cases  in  which  it 
was  used  the  process  ran  a  much  shorter  course  than  usual. 

OPERATIONS    ON    THE    HAND    AND   ARM. THE    FINGERS. No    TC- 

gion  requires  a  more  delicate  technic  if  the  patient  is  to  be  spared 
needless  pain.     A  fine  new  sharp  needle  is  indispensable.     The 


288 


Surgical  Operations  with  Local  Anesthesia 


dull-pointed  needles  on  the  market  expressly  for  use  in  local 
anesthesia  are  unsuitable.  A  small  syringe  must  be  used,  pre- 
ferably a  glass  one  of  i  cc.  capacity.  The  large  syringes  are  un- 
suited,  because  very  slow  injections  cannot  be  made  with  instru- 
ments of  large  diameter. 


Fig.  152.     Lines  of  skin  infiltration  on  the  palmar  surface  corresponding  to  the 
dorsal  infiltration  in  Fig.  151. 

AMPUTATIONS. — In  amputations  of  the  distal  phalanx,  or  in 
opening  abscesses  in  this  region,  the  skin  about  the  base  of  the 
finger  is  first  infiltrated,  beginning  at  the  dorsum,  because  this 
is  the  least  sensitive  part,  and  proceeding  toward  the  palmar  sur- 
face. After  a  complete  ring  has  been  infiltrated  the  digital  nerves 


Surgical  Operations  with  Local  Anesthesia  289 

are  blocked  (Fig.  150).  On  each  side  of  the  bone  the  needle  is 
passed  downward  and  inward.  The  dorsal  nerve  is  encountered 
near  the  central  plane  of  the  bone  and  the  ventral  opposite  the 
flexor  tendons. 

When  the  first  phalangeal  bone,  or  the  metacarpo-phalangeal 
joint,  is  to  be  attacked  the  line  of  skin  infiltration  begins  on  the 
dorsum  of  the  hand  an  inch  or  two  above  the  joint.  Diverging 
lines  are  infiltrated,  which  terminate  in  the  webs  on  each  side 
of  the  finger  (Fig.  151).  When  the  web  has  been  reached  a  simi- 
lar triangle  is  described  on  the  palmar  surface  in  the  reverse 
direction,  terminating  at  a  point  opposite  the  point  of  beginning 
(Fig.  152).  The  nerves  are  now  blocked  by  passing  the  needle 
downward  from  the  dorsum  on  each  side  of  the  bone  (Fig.  153), 
and  upward  through  the  web  parallel  with  the  nerves  it  is  intend- 
ed to  block.  If  the  metacarpal  bone  is  to  be  attacked  the  perios- 
teum must  be  infiltrated.  This  can  be  done  most  effectively  by- 
passing the  needle  along  the  bone  from  the  web  (Fig.  153).  Each 
finger  to  be  operated  on  is  injected  in  the  same  manner.  If  sev- 
eral fingers  are  to  be  operated  on  at  the  same  setting  the  skin 
lines  of  infiltration  to  the  web  should  be  made  to  bound  the  field 
of  operation,  but  the  nerves  on  each  side  of  the  metacarpal  bones 
must  be  blocked  separately  (Fig.  151). 

For  operations  upon  the  distal  phalanx  anesthesia  may  be  at- 
tained by  the  method  just  described  instead  of  by  circling  the 
base  of  the  finger,  but  in  limited  operations  the  latter  method  is 
simpler. 

Operations  upon  the  carpal  and  proximal  ends  of  the  meta- 
carpal bones  must  be  preceded  by  blocking  about  or  above  the 
wrist.  A  circular  line  is  infiltrated  and  from  this  the  nerves 
supplying  the  region  are  infiltrated.  The  extent  of  this  infiltra- 
tion must  depend  upon  the  extent  of  the  operation.  If  a  single 
metacarpal  bone  is  to  be  attacked  injection  about  its  base  from 
the  circular  line  will  be  sufficient.  If  more  than  one  is  to  be  at- 
tacked each  in  turn  must  be  similarly  infiltrated. 

Instead  of  infiltrating  about  the  bone  to  be  attacked  the  nerve 
trunks  may  be  blocked  above  the  wrist.  A  circular  line  is  first 


290 


Surgical  Operations  with  Local  Anesthesia 


infiltrated  in  the  skin  and  subcutaneous  tissues  (Fig.  156).  This 
blocks  all  superficial  nerves  in  this  region.  Through  this  pri- 
mary line  the  main  trunks  are  injected  (Fig.  157).  This  method 
of  anesthetization  is  required  for  all  extensive  operations  on 
the  wrist  and  hand. 


Fig.  15!5.     Infiltration  of  the  periosteum  when  the  metacarpal  is  to  be  attacked. 

For  operations  upon  the  metacarpal  of  the  thumb  this  pro- 
cedure may  be  modified.  Instead  of  infiltrating  a  line  entirely 
about  the  wrist  this  line  is  terminated  over  the  carpo-metacarpai 
joint  and  the  line  continued  to  the  web  of  the  thumb,  both  fore 


Surgical  Operations  with  Local  Anesthesia  291 


Fig.  Io4.     Circular  injection  about  the  wrist.     Needles  showing  direction  of  blocking 
the  radial  and  ulnar  nerves*. 


Sup.  branch  ot 
'    uln«r  nerve 


Fig.  155.     Cross-section  of  the  wrist  showing  the  nerves  to  be  blocked. 


292  Surgical  Operations  with  Local  Anesthesia 

and  aft  (Figs.  156  and  157).     From  this  line  deep  injections  arc 


Fig.  loG.     Infiltration  about  the  base  of  the  metacarpal  bone  of  the  thumb.    The  needles 
indicate  the  points  for  deep  injection. 

made.     This  technic  is  useful  also  in  certain  dislocations  of  the 
thumb. 

In  lacerated  wounds  of  the  hand  the  skin  injection  is  begun 
at  one  angle  of  the  wound,  and  from  this  point  the  injured  area 


Suryical  Operations  with  Local  Anesthesia 


293 


is  circumscribed  and  the  deeper  tissue  then  injected.  This 
method  of  injection  causes  less  pain  and  is  less  likely  to  cause 
infection  than  if  the  skin  is  injected  from  the  edges  of  the 
wound. 


Fig.  157.     Superficial  and  deep  injections  on  the  palmar  surface  for  operations  upon 
the  metacarpal  bone  of  the  thumb. 

INFECTION  OF  THE  FINGERS. — Superficial  infection  may  be  in- 
jected directly  in  the  line  of  the  proposed  incision,  but  in  more 
severe  infections  it  is  best  to  block  off  the  entire  finger  as  rec- 
ommended for  amputation  (Fig.  150). 


294 


Surgical  Operations  with  Local  Anesthesia 


If  the  operator  will  use  judgment  the  patient  may  be  saved 
many  hours  of  acute  suffering  by  using  quinine  for  anesthesia 
in  operating  abscesses.  If  too  much  anesthetic  fluid  is  injected 
the  circulation  is  disturbed  and  the  necrosis  of  the  disease  aug- 
mented. 

INFECTIONS  OF  THE  PALM. — Simple  isolated  infections  may  be 
incised  through  a  simple  infiltration  line  in  the  skin  covering 
them.  The  diffuse  infections  should  be  done  under  gas  or  ether, 
or,  if  these  are  not  available  or  are  contraindicated,  by  blocking 
of  the  nerves  above  the  area  of  infection,  or  by  plexus  anes- 
thesia. 


Fig.  153.     Circular  injection  of  the  arm  with  blocking  of  the  nerve 
trunks  above  the  elbow. 

Operations  upon  the  forearm  may  be  done  following  a  cir- 
cular infiltration  above  the  elbow  with  subsequent  blocking  of 
the  nerve  trunks  (Fig.  158).  When  for  some  reason  local  anes- 
thesia is  necessary  for  large  operations,  they  are  better  done 
under  plexus  anesthesia.  If  the  latter  is  incomplete  it  may  be 
supplemented  by  local  infiltration. 

Bursae  of  the  olecranon,  or  abscesses  or  exostoses  resulting 
from  them,  may  be  attacked,  infiltrating  a  line  about  them  and 
injecting  deeply  beneath  them  from  this  line  (Fig.  159).  In 
thickened  bursae  the  needle  can  readily  be  passed  between  the 
cyst  wall  and  the  bone,  but  in  recent  ones  this  may  not  be  possi- 
ble. In  that  event  the  border  of  the  bursa  is  freely  infiltrated, 
which  secures  ample  anesthesia  after  a  wait  of  ten  minutes. 


Surgical  Operations  with  Local  Anesthesia 


295 


PLEXUS  BLOCKING. — Crile  first  blocked  the  cervical  plexus  by 
laying  bare  the  nerves  above  the  clavicle.  Herschel  (Verhandl. 
d.  Deutsch.  Gesellseh.  f.  Chir.  r.}  1912,  XLI,  348)  attained  the 
same  result  by  passing  the  needle  from  the  axilla,  and  Kulen- 
kampf  (Zentralbl.  f.  Chir.,  1911,  XXXVIII,  1336)  by  passing 
the  needle  above  the  clavicle.  The  last  two  methods  will  be 
described. 

Herschel 's  Method.  The  patient  is  laid  flat  on  the  table  with 
the  arm  in  extension.  The  brachial  artery  is  located  by  palpa- 
tion. The  needle  is  passed  through  the  skin  in  a  direction  par- 


Fig,  loit.     Injection  superficial  and  deep  for  operation  upon  the  olecranon. 

allel  with  the  artery,  from  a  point  over  the  insertion  of  the 
latissimus  dorsi.  The  needle  is  passed  parallel  with  the  artery 
for  ten  centimeters,  and  I  -  cc.  of  a  2%  novocain-epinephrin  solu- 
tion is  deposited  in  an  area  of  3  or  4  cm.  The  needle  is  with- 
drawn until  the  point  is  just  beneath  the  skin  and  is  then  re- 
introduced  lateral  to  the  artery  in  order  to  reach  the  median 
nerve.  The  musculo-cutaneous  nerve  may  be  reached  by  passing 
the  needle  high  into  the  axilla  toward  the  first  rib,  but  this  is  not 
needed  in  operations  involving  the  hand  only.  If  the  nerves 
are  directly  penetrated,  which  is  manifested  by  paresthesias, 
anesthesia  is  instantaneous.  Ordinarily  the  anesthetic  is  de- 
posited in  the  vicinity  of  the  nerve  and  anesthesia  is  not  complete 
for  20  or  30  minutes. 


296  Surgical  Operations  with  Local  Anesthesia 

The  objection  to  this  method  is  the  same  that  applies  to  any 
in  which  the  anesthetization  of  large  nerve  trunks  depends 
upon  diffusion — irregularity  in  onset  and  'uncertainty  of  effect. 
Lying  as  the  nerves  do  in  close  proximity  to  the  axillary  artery 
and  veins,  these  structures  are  liable  to  injury.  Herschel  states 
that  such  injury  is  of  no  consequence.  I  have  tried  puncturing 
large  vessels  with  a  needle  when  they  are  exposed  during  opera- 
tion. The  escape  of  blood  is  considerable.  Cases  are  reported 
in  which  troublesome  after-effects  have  followed  on  account  of 
hemorrhage.  Puncture  of  the  vessels  is  unlikely  if  a  puddle  of 
the  fluid  is  kept  constantly  ahead  of  the  needle  as  it  is  being 


Fig.  IfiO.     Point  at  the  midclavicular  region  where  needle  is  entered.     I  Kulenkampf). 


pushed  forward.  Troublesome  paralyses  have  resulted  from  this 
method,  but  none  so  far  as  reported  have  remained  perma- 
nently. 

Kulenkampf s  Method.  This  method  probably  is  more  cer- 
tain in  its  action  because  its  aim  is  to  penetrate  the  nerves  and 
it  is  less  likely  to  injure  the  large  vessels,  because  the  vulnerable 
parts  have  constant  anatomical  relations  and  can  easily  be  avoid- 
ed. It  is  as  follows :  with  the  patient  in  the  sitting  position 
the  artery  is  palpated.  It  is  usually  found  about  the  midpoint 
of  the  clavicle  (Fig.  160).  A  line  uniting  this  point  with  the  tip 
of  the  spinous  process  of  the  first  dorsal  vertebra  (Fig.  161) 


Surgical  Operations  with  Local  Anesthesia  297 

passes  through  the  cervical  plexus.  In  thin  subjects  the  nerves 
may  be  directly  palpated  where  they  pass  over  the  rib.  From 
the  point  above  given  a  needle  is  passed  in  the  direction  of  the 
imaginary  line,  uniting  the  point  to  the  tip  of  the  first  dorsal 
spine.  Placing  the  tip  of  the  left  forefinger  on  this  spine  helps  to 
maintain  the  direction.  The  plexus  is  reached  at  a  depth  of  from 
y2  to  3  cm.  (Fig.  162).  The  penetration  of  the  nerves  is  mani- 
fest by  paresthesias  in  the  region  of  distribution  of  the  nerves 
affected.  If  the  first  attempt  does  not  succeed  the  direction  of 
the  needle  must  be  varied  until  the  nerves  are  pierced.  Infiltra- 
ton  of  these  nerves  does  not  cause  anesthesia  in  the  upper  por- 
tion of  the  arm,  and  when  operations  about  the  shoulder  are  to 
be  performed  infiltration  of  the  skin  and  subcutaneous  tissue 
is  required.  For  the  plexus  injection,  10  cc.  of  a  2%  solution 
are  deposited  when  the  needle  penetrates  the  nerve,  and  a  few 
more  a  short  distance  deeper.  If  anesthesia  is  not  complete,  an 
additional  5  or  10  cc.  of  a  4%  solution  is  used.  Novocain-epine  • 
phrin  is  always  used. 

In  100  cases  recorded  by  Kulenkampf  the  method  failed  in  four 
cases.  In  19  cases  some  areas  were  not  completely  anesthe- 
tized. Kulenkampf  regards  accidental  puncture  of  the  artery 
as  free  from  danger. 

Injury  to  the  nerves  has  resulted  from  puncture  of  the  nerve 
roots,  but  in  no  case  has  there  been  permanent  disability.  Hirsch- 
ler  reports  three  cases  in  which  circumscribed  paralysis  or  sen- 
sory disturbances  remained  for  a  considerable  time.  He  ad- 
vises that  those  whose  occupations  require  delicate  manipula- 
tions with  the  fingers,  such  as  fine  mechanics,  violinists,  and 
pianists,  be  not  subjected  to  this  method  of  anesthesia. 

Plexus  blocking  is  applicable  to  all  operations  upon  the  arm 
and  hand,  and  is  particularly  useful  for  individuals  who  are 
affected  with  other  disorders,  and  in  cases  where  thoracic  inju- 
ries make  inhalation  anesthesia  undesirable. 

Hartel  and  Keppler  (Arch.  f.  Klin.  Chir.,  1914,  CIII,  i)  report 
paralysis  of  the  diaphragm  on  the  injected  side  in  17  out  of  200 


298 


Surgical  Operations  with  Local  Anesthesia 


cases.  This  should  warn  against  injecting  both  plexuses  at  one 
sitting.  In  5  cases  they  observed  severe  pain  in  the  chest  and 
dyspnoea,  which  they  believe  was  due  to  the  puncture  of  the 


Fig.  161.     Direction  in  which  the  needle  is  passed  from  the  middle  point  of  the  clavicle 
toward  the  tip  of  the  first  dorsal  spine.     (Kulenkampf). 


Fig.  162.     Topographic  anatomy  of  the  region  involved  in  plexus  anesthesia  :  a, 
omohyoid  muscle  ;  b,  brachial  plexus  ;  c,  subclavian  artery  ;  d,  scalenus 
anticus;  e,  sterno-mastoid.     (Kulenkampf). 

pleura.  In  the  light  of  my  recent  experience  I  would  suggest 
that  it  may  be  due  to  massive  collapse  of  the  lung  due  to  paraly- 
sis of  the  phrenic  nerve. 


Surgical  Operations  with  Local  Anesthesia 


30  f 


Because  of  the  long  duration  of  its  effect  quinine  is  distinct, 
the  anesthetic  of  choice  for  this  operation. 

Instead  of  the  method  above  described  a  circular  line  r.boiu 
the  base  of  the  toe  may  be  injected  and  other  nerves  leading  to 
the  diseased  area  blocked  by  deep  injections  at  the  base  of  llir 
toe,  as  shown  for  operations  on  the  fingers. 


Fig.  166.     Dorsal  line  of  infiltration  for  amputation  of  the  toes. 

AMPUTATION  OF  THE  TOES. — The  amputation  of  toes  is  accom- 
plished in  a  manner  similar  to  that  described  for  amputation  of 
the  fingers.  Since  amputation  of  the  toes  is  rarely  performed 
distal  to  the  metatarso-phalangeal  joint,  the  triangular  infiltra- 
tion over  the  dorsum  and  plantar  surfaces  with  deep  infiltration 
from  these  lines  is  the  method  usually  employed. 


302  Surgical  Operations  -with  Local  Anesthesia 

Near  the  base  of  the  metatarsal  joint  an  infiltration  line  de- 
scends to  the  web  on  either  side  of  the  toe  or  toes,  which  are  to 
be  operated  upon  (Fig.  166).  From  the  point  of  termination  of 
these  lines  at  the  web  other  lines  are  infiltrated  upon  the  sole  to 
terminate  at  a  common  point  opposite  the  point  of  beginning  on 
the  dorsum.  From  the  web  line  deep  infiltrations  are  made 
along  the  bone,  as  shown  in  operations  upon  the  fingers.  From 
the  point  of  beginning  on  the  dorsum  the  deeper  tissues  are  in- 
filtrated, extending  through  the  foot  to  the  sole,  as  shown  in 
operations  on  the  hand.  This  gives  an  anesthesia  which  permits 
metatarso-phalangeal  disarticulation  or  amputation  through  the 
shaft  of  the  metatarsal,  as  is  required  in  metatarsalgia.  Ampu- 
tations of  the  great  toe  may  be  done  under  the  technic  advised 
for  bunion. 

INJURIES  TO  THE  FOOT. — Puncture  of  the  foot,  particularly  the 
sole,  by  nails  or  other  foreign  bodies,  is  one  of  the  most  frequent 
surgical  lesions  encountered  by  the  general  practitioner.  The 
frequency  with  which  tetanus  follows  these  injuries  makes  their 
proper  treatment  of  the  greatest  importance.  If  the  wound  is 
fresh  it  is  imperative  that  the  entire  tract  be  exposed  immediately 
and  that  the  entire  area  which  came  in  contact  with  the  foreign 
body  be  thoroughly  cauterized  and  the  wound  packed.  This  pro- 
cedure demands  a  careful  anesthesia.  If  the  wound  be  clean  the 
needle  may  be  introduced  along  the  tract  of  the  foreign  body 
and  the  infiltration  begun  in  the  subcutaneous  tissue.  This 
method  saves  a  preliminary  puncture  of  the  thick  and  sensitive 
skin,  but  it  is  open  to  the  objection  that  infection  present  in  the 
wound  may  be  carried  to  the  deeper  structures.  Some  idea  of 
the  depth  and  direction  of  the  puncture  must  be  obtained  from 
the  history  of  the  injury  in  order  that  an  area  large  and  deep 
enough  may  be  infiltrated.  If  the  wound  is  deep,  extending  to 
near  the  dorsum,  it  may  be  advantageous  to  begin  the  infiltra- 
tion on  the  dorsum  and  gradually  approach  the  site  of  the  wound 
on  the  sole.  The  dorsum  is  less  sensitive  and  the  skin  less  resis- 
tant. Often  by  these  means  it  is  possible  to  operate  children  who 


Surgical  Operations  with  Local  Anesthesia  303 

would  not  permit  the  operator  to  force  the  needle  through  the 
resistant  plantar  skin.  This  applies  particularly  in  boys  who 
have  been  going  barefooted. 

Wounds  already  infected  can  more  frequently  be  satisfactorily 
opened  under  local  anesthesia  in  the  foot  than  in  the  hand,  be- 
cause of  the  lesser  tendency  for  the  infection  to  follow  the  ten- 
don sheaths.  The  infiltration  must  begin  in  healthy  skin  and  the 
infected  area  gradually  be  approached  or  circumscribed,  depend- 
ing on  the  degree  and  character  of  the  infection.  Infections  fol- 
lowing the  tendon  sheath,  like  those  of  the  tendon  sheaths  of 
the  hand,  demand  general  anesthesia. 

HALLUX  VALGUS. — From  a  point  two  inches  above  the  joint 
on  the  medial  border  of  the  foot  to  a  point  between  the  meta- 
tarsal  bones  to  the  web  of  the  toes  the  skin  is  infiltrated  (Fig. 
167).  From  the  same  point  a  line  is  infiltrated  over  the  inner  bor- 
der of  the  foot  to  a  point  on  the  sole  corresponding  to  the  point, 
of  beginning  (Fig.  168).  From  the  terminal  point  of  the  first  in- 
filtration on  the  web  a  line  is  now  injected  to  the  point  on  the  sole 
of  the  foot.  From  the  first  point  injected  the  interosseus  nerves 
are  blocked,  and  the  periosteum  is  infiltrated.  From  the  point  on 
the  sole  of  the  foot  the  periosseus  tissues  likewise  are  infiltrated. 
This  may  be  accomplished  by  injecting  from  the  webs  of  the  toes 
(Fig.  169).  This  operation  deals  with  sensitive  tissue,  and  a  con- 
siderable amount  of  the  fluid,  usually  40  to  50  cc  of  a  l/2%  of 
novocain-epinephrin  solution,  should  be  used. 

THE  TENDO  ACHiLLis. — Operative  lengthening  of  this  tendon 
is  usually  part  of  a  serious  operation  not  usually  undertaken 
under  local  anesthesia.  Rupture  of  the  tendon  offers  a  more  fre- 
quent object  for  the  employment  of  local  anesthesia.  It  is  desir- 
able that  the  skin  incision  shall  not  fall  directly  over  the  repaired 
tendon.  A  curved  line,  therefore,  is  infiltrated  from  a  point 
over  the  tendon,  beginning  two  inches  below  the  site  of  injury, 
curving  outward  over  the  tendon,  beyond  the  tendon  and  termi- 
nating over  the  tendon  two  inches  above  the  injury  (Fig.  170). 
From  the  points  of  beginning  and  termination  of  the  line  the 


304  Surgical  Operations  with  Local  Anesthesia 


\%.  KiT.     Superficial  and  deep  dorsal  infiltration  tor  hallux  valjfi 


1(W.     Plantar  infiltration  for  hallux  valgus. 


Siiryical  Operations  ivith  Local  Anesthesia 


305 


tendon  is  circumscribed  with  fluid.  By  sliding  the  skin  both 
sides  of  the  tendon  may  be  reached  by  the  needle  without  making 
a  new  puncture  in  an  unanesthetized  area.  The  area  below  the 
tendon  can  best  be  reached  from  a  point  in  the  original  line  where 


Fig.  109.     Deep  infiltration  from  the  web  of  the  toes. 

this  crosses  the  furrow  below  the  tendon.  By  making  the  inci- 
sion along  the  line  of  the  original  infiltration  a  flap  is  formed 
which,  when  returned  after  the  repair  is  made,  places  the  line 
of  incision  outside  from  the  recently  repaired  tendon. 

In  open  injury  of  this  tendon  and  others  of  the  foot  an  ellipse 
should  be  circumscribed  an  inch  or  two  from  the  site  of  injury 


306 


Surgical  Operations  with  Local  Anesthesia 


from  which  to  infiltrate  the  deeper  tissues.  Should  the  injury 
involve  or  lie  near  a  prominent  nerve,  the  infiltration  is  made 
with  the  view  of  striking  the  nerve. 

VARICOSE  VEINS  AND  ULCERS. — Dilated  veins  and  the  ulcers  re- 
sulting from  them  are  frequent  diseases  in   fat  old  women  ii> 


Fig    170.     Infiltration  of  the  skin  in  the  line  of  incision.     At  a  and  b  infiltration 
is  made  above  and  below  the  tendon. 

whom  ether  anesthesia  is  to  be  avoided.  They  can  be  managed 
under  local  anesthesia  by  the  exercise  of  patience  and  care  in 
manipulation  on  the  part  of  the  operator. 

It  will  be  necessary  to  resect  the  veins  below  the  saphenous 
opening  and  also  some  segments  below  the  knee,  the  location  of 


Surgical  Operations  with  Local  Anesthesia 


307 


which  can  be  determined  when  the  patient  is  on  her  feet.  The 
skin  over  the  vein  is  infiltrated  in  the  usual  manner  (Fig.  171). 
The  tissue  about  and  below  the  vein  can  be  infiltrated  by  sliding 
the  skin  first  on  one  side  and  then  on  the  other.  For  this  pur- 
pose a  considerable  amount  of  weak  solution,  %%  or  less,  is 
used  in  order  to  facilitate  the  dissection  of  the  veins.  The  vein 


Fig.   171.     Inclination  of  skin  over  a  varicose  vein. 


should  be  dissected  in  plain  sight  so  that  collaterals  may  be  seen 
before  they  are  cut.  They  should .  all  'be  ligated,  for  while  they 
may  not  bleed  at  the  time  of  the  operation,  they  may  do  so  later. 
If  the  vein  from  previous  periphlebitis  has  become  adherent  to 
the  subcutaneous  tissue  it  is  best  to  infiltrate  an  ellipse  about  the 
mass  and  excise  it  as  a  whole. 

The  removal  of  a  varicose  ulcer  is  more  difficult,  because  it 
involves  the  periosteum  and  because  the  skin  about  it  is  often 
very  sensitive.  I  have  developed  a  typical  operation,  performed 


3o8 


Surgical   Operations  with  Local  Anesthesia 


as  follows :    the  solution  is  injected  about  the  border  of  the  ulcer 
(Fig.  172)  through  approximately  normal  skin.     From  this  line 


Fij;.  ]~'2.     Superficial  and  deep  injection  for  the  removal  of  varicose  ulcer  of  the  leg. 

the  periosteum  is  infiltrated  over  the  entire  base  of  the  ulcer,  a 
procedure  which  is  facilitated  by  the  presence  of  a  considerable 
amount  of  fibrous  tissue.  If  the  ulcer  is  large  and  consequently 


Sunjical  Operations  :^'ith  Local  Anesthesia  309 

curved  it  may  be  necessary  to  make  some  of  the  infiltration 
through  the  base  of  the  ulcer.  When  the  infiltration  is  complete, 
the  skin  is  incised  in  the  line  of  the  first  injection,  and  the  ulcer 
is  dissected  from  its  base  with  its  floor  intact.  The  ulcer  thus 
excised  forms  a  flat  saucer. 

In  preparing  the  bed  of  an  ulcer  for  skin-grafting  a  small 
amount  only  of  epinephrin,  say  two  drops  to  the  ounce,  should 
be  used,  so  as  to  produce  the  least  amount  of  constriction  of  the 
vessels  and  allow  a  quicker  recovery  of  their  normal  tone.  One 
must  depend  upon  the  exudate  from  the  vessels  to  supply  the 
preliminary  fixation  of  the  graft.  In  operations  of  this  kind  it 
is  well  to  prepare  the  ulcer  as  the  first  step.  By  the  time  the 
varicose  veins  have  been  resected  and  the  area  from  which  the 
new  skin  is  to  be  secured  has  been  prepared,  the  vascular  tone  in 
the  bed  of  the  excised  ulcer  has  been  to  a  certain  extent  restored. 
With  all  this  precaution  there  will  be  a  greater  percentage  of 
failures  than  if  no  local  anesthetic  at  all  is  used. 

The  method  of  preparing  the  skin  from  which  the  graft  is  to 
be  taken  may  be  varied  according  to  the  size  of  the  graft.  If  it 
is  small.,  the  area  from  which  the  graft  is  to  be  taken  may  be  in- 
filtrated subdermically  and  surrounded  by  a  horseshoe-shaped 
endermic  infiltration. 

For  anesthetizing  the  skin  preliminary  to  removing  the  grafts 
quinine  is  better  than  novocain-epinephrin,  because  the  former 
produces  a  preliminary  capillary  hyperemia  which  assures  an 
abundance  of  serum  which  is  necessary  to  assure  ideal  healing 
of  the  grafts.  Novocain-epinephrin,  on  the  other  hand,  by  virtue 
of  the  anemia  it  produces,  furnishes  a  blanched  serumless  graft. 
This  is  of  more  importance  in  where  particularly  thick  grafts 
are  required,  as  for  covering  defects  on  the  tibia  or  skull. 

For  large  grafts  the  same  method  may  be  used,  or  the  nerves 
to  the  area  may  be  blocked.  The  nerves  concerned  are  the  lateral 
cutaneous,  femoral  and  the  anterior  cutaneous.  The  former 
emerges  medial  to  the  anterior  superior  spine  and  below  the 
Poupart's  ligament.  In  order  to  block  it  Loewen  (Dentsch  Ztsch. 


310  Surgical  Operations  with  Local  Anesthesia 

fur  Chir.,  1911,  LXI,  252)  suggests  that  the  most  favorable 
point  is  two  finger-breadths  downward  and  inward  from  the  an- 
terior superior  spine.  Two  or  three  cc.  of  the  solution  are  depos- 
ited above  and  below  the  fascia,  the  needle  being  directed  down- 
ward and  outward.  To  reach  the  anterior  crural  nerve,  Loewen 
gives  the  following  directions :  the  femoral  artery  is  located 
by  the  finger  at  its  emergence  below  Poupart's  ligament.  The 
needle  is  passed  one  and  one-half  cm.  lateral  to  this  point  per- 
pendicular to  the  surface  until  it  penetrates  the  fascia  lata. 
While  the  needle  is  passing  5  cc.  of  a  2.%  solution  are  deposited. 
Puncture  of  the  nerve,  which  should  be  done  if  possible,  is  mani- 
fested by  a  contraction  of  the  rectus  femoris.  After  the  nerve 
has  been  penetrated  the  fluid  is  deposited. 

When  the  nerves  have  been  successfully  blocked  a  large  area 
is  made  anesthetic.  This  method  has  the  advantage  over  direct 
infiltration  of  the  skin  that  the  capillary  circulation  is  not  inter- 
fered with.  Its  disadvantage  lies  in  the  fact  that  it  is  not  always 
certain  that  the  nerves  will  be  effectually  blocked,  especially  in 
fat  persons. 

PATELLAR  BURSixis. — For  the  treatment  of  this  common  affec- 
tion one  injects  first  a  line  of  skin  around  the  base  of  the  swelling 
and,  second,  through  this  line  the  periosteum  beneath  the  bursa 
(Fig.  173).  The  second  step  is  especially  easy  if  the  periosteum 
has  become  thickened  by  prolonged  inflammation.  In  recent 
cases  where  the  thinness  of  the  tissue  may  make  this  uncertain, 
the  fluid  from  the  cyst  is  replaced  by  a  5%  quinine  solution. 
The  bursa  is  then  dissected  out  in  the  usual  way. 

Ganglia  about  the  knee  are  removed  by  infiltrating  the  skin 
over  them  and  the  tissue  surrounding  them.  Sometimes  their 
deep  attachments  remain  sensitive  and  require  a  secondary  infil- 
tration during  the  course  of  the  operation. 

TUMORS. — Many  tumors  of  the  soft  parts  may  be  removed 
under  local  anesthesia.  It  is  best  to  infiltrate  about  them  with- 
out regard  to  the  nerve  supply.  Tumors  with  deep  attachment 


Surgical  Operations  with  Local  Anesthesia  311 

should  be   undertaken  with  caution  and  the  operator  must  be 
prepared  to  infiltrate  periosteal  or  deep  fascial  attachments. 

Blocking  of  the  nerves  of  the  leg  in  a  manner  analogous  to 
plexus  anesthesia  in  the  arm  is  not  possible  because  of  the  num- 
erous avenues  of  exit  of  the  nerves  supplying  the  leg.  The 
sciatic  may  be  reached  at  a  point  slightly  medial  to  the  center  of 


Fig.  173.     Superficial  and  deep  infiltration  for  removal  of  the  prepatellar  bnrsa. 

a  line  between  the  trochanter  and  the  tuberosity  of  the  ischium. 
The  only  purpose  for  which  this  nerve  is  likely  to  be  injected  is 
to  control  the  pain  in  sciatica.  By  injecting  10  cc.  of  a  i%  solu- 
tion of  quinine  into  the  nerves,  one  can  not  only  control  the  pain 
for  some  days,  but  can  also  bring  about  a  cure  in  many  cases. 

Aiajor   operations   about   the   knee  may  be  performed   under 
venous   anesthesia.     The   indications    for  arthrotomy  are  often 


312  Surgical  Operations  zvith  Local  Anesthesia 

such  as  to  make  the  case  unsuited  for  venous  anesthesia.  In- 
fected legs  or  joints  preclude  its  use.  In  loose  bodies  or  loose 
cartillages  it  finds  ideal  application.  Unless  the  patient  has  had 
a  full  dose  of  morphine  before  the  operation  he  is  apt  to  com- 
plain bitterly  of  the  pressure  from  the  constricting  band.  All 
these  disadvantages  will  prevent  this  method  becoming  popular. 
Major  operations  on  the  leg  and  thigh  under  nerve  blocking- 
belong  to  the  "stunts"  in  local  anesthesia  and  are  useful  only  for 
the  purpose  of  demonstrating  the  spearing  prowess  of  the  opera- 
tor. In  major  operations  upon  the  thigh,  one  may  employ  spinal 
anesthesia  where  gas  or  ether  cannot  be  used.  Spinal  anesthesia 
is  less  objectionable  than  the  massive  injections  of  the  leg  re- 
quired for  extensive  operations  under  local.  Loewen  used  2.1 
gm.  novocain  in  order  to  make  the  whole  thigh  anesthetic.  Such 
a  quantity  of  the  drug  makes  the  procedure  more  hazardous  than 
spinal  anesthesia. 


INDEX 


Abdomen,    operations    on,     161. 

exploratory    operations    on,     170. 

nerves    of,    164. 

operations    on   wall    of,    161. 

sensibility,     164. 
Abscess,    lung,    drainage    of,     152. 

opening    of,    58. 

subdiaphragmatic,     154. 
Adrenalin,    see    epinephrin,    20,    22. 
Alexander — Adams   Operation,    261. 
Alypin,     18. 
Amputations 

fingers,    288. 

penis,     220. 

tower    extremities,    301. 

scrotum,    229. 
Anal    fissures,    operations    of,    280. 

fistula,     275. 

sphincter,     dilatation,    of    270. 
Anesthesia,    combined,    22. 

drugs    employed    in,    i. 

duration    of, 

in    control    of    after-pain,    44. 

in    control    of    shock,    51. 

sequential,     19. 
Anesthetization,    methods    of,    31. 

endermic    infiltration,    32. 

subdermic    infiltration,    35. 

nerve    blocking,    36. 

edematization,    37. 
Antrum,    operations    on,    80. 
Apparatus,   care   of,   25. 
Appendectomy,     179. 
Application,    methods    of,    25. 

injection,    31. 
Aspiration   of  pleural   exudate,    148. 


I! 


Bier,    intravenous    method    of,    39. 
Beta-Eucain,    18. 
Bladder,    stones    in,    233. 

tumors    of,    235. 

Bonain,   anesthetic   solution   of,    94. 
Breast,    abscess    of,    133. 


Schleichs    solution    of,    4. 

strength    used,    2,    4. 

topical     application     of,     i. 

toxicology    of,    6. 

treatment    of    poisoning   by,    6. 
Colostomy,    technic    of,    178. 
Cranium,    nerves    of, 

operations    on,    64. 

tumors    of,    67. 

Cranial   contents,   operations   on,   72. 
Curretage    of    uterus,    243. 
Cystoscopy,    anesthesia    in,    253. 
Cystotomy,    234. 


1) 


Dangers    of    cocain,    6. 
Dilatation,     anal     sphincter,     270. 

of    uterus,    243. 
Drainage,    abdominal    cavity, 

king   abscess,    132. 

pleural    cavity,     148. 
Drugs  employed  in  local  anesthesia, 

alypin,    18. 

anesthesin,    18. 

beta-eucain,    18. 

cocain,    i. 

noyocain,     15. 

quinine  and   urea   hydrochloride,   7. 

stovain,    18. 

subcutin,    18. 

tropacocain,     18. 


Ear,    operations    on,    93. 

drum,    perforation    of,    93. 
Epinephrin,   20. 

dangers   of,    22. 

Kthyt    chloride    in    local    anesthesia,    23. 
Kxternal    urethrotomy,    233. 
Extremities,    operations    on,    282. 

lower,    operations    on,    203. 

upper,    operations    on,    288. 
Exploratory    laparotomy,     170. 


Carcinoma  of  uterus,  operation  on,  261. 
Car.tration,    technic    of,    231. 
Cervical    glands,    removal   of,    85. 
Cervix,    repair   of,    241. 
Circumcision,    technic    of,    216. 
Cocain,    application    of,    i. 

dangers    of.    6. 

injection    of,    3. 


Face,    operations    on,    73. 
Fingers-.,    amputations    of,    288. 

infections    of,    293. 
Fischer's    solution    of    novocain,    16. 
Fistula    in    ano,    275. 
Foreign   bodies,    search    for,    62. 
Fractures    of    extremities,    283. 
Freezing    as    a    local    anesthetic,    23. 
Freund-Wertheim     operation,     260. 


Index 

G  Lungs,  abscess  of,    152. 

operations    on,    141. 

Car.serian  ganglion,  injection   of,  99.  Local    anesthesia, 

operations    on,  drugs    vised    in,    i. 

First    branch,   108.  in    the    control    of    after-pain,    44. 

Second    branch,     no.  general     principles     of,     25. 

Third    branch,     112. 

('.all-bladder,     operations     on,     180.  ,, 

Gastro-enterostomy,     176. 
Gastrostomy,     175. 

General    anesthesia,  Mammary  glands,   operations  on,    133. 

combined    with    local,    22.  benign    tumors    of,     133. 

diagnostic    incision    ot,     134. 
mixed    tumors    of, 

II  malignant    tumors    of,     133. 

radical    amputation    of,    137. 

Hallux,    valgus,    303.  Mastoid,    operations   of,   94. 

Harris'    solution,     16.  radical    cure    of,    137. 

Hemorrhoids,     external,     267.  Mediastinum,    operations    on,     155. 

internal,     270.  Montgomery     operation,     262. 

Hernia,     182.  Morphine,    preliminary    use    of,    29. 

femoral,    204.  dosage    of,    29. 

strangulated,     206.  indications    for,    29. 

inguinal,    188.  Mouth,   floor   of,   operations  on,   92. 

strangulated,    203.  operations   on,    73. 

linea    alba,    186.  operations  on   soft   parts   of,   92. 

pofit    operative,    186. 

scar,     1 86.  ^ 

umbelical,    183. 

Ilydrocele,     operation     for,    230.  Nails     removal    of    ingrowing,    137. 

Hysterotomy,    245.  Xeck,    operations   on,    92. 

Hysterectomy,     261.  Xerve    blockillg     a6. 

Hyperesthesia    beyond    anesthetic    area,        \ovocain      15 

Harris'     solution     of,     16. 
j  methods    of    use,     17. 

strength  of   solution,    15. 

Infections    of    extremites,    282.  toxicity,     18. 

lingers,     293.  . 

palm,    294.  Q 

Infraorbital    nerve,    resection   of,    in. 

Ingrowing    nails,    294.  Orbit,    operations    on,    73. 

Inguinal     region,    nerves    of,     189. 
hernia,     188. 

strangulated,    203.  P 

Internal    hemorrhoids,    270. 
Intravenous   anesthesia,   39.  Palm,    infections    of,    294. 

Pantopon,  as  a  preliminary  hypnotic,  29 
Paracentesis,    148. 
J  Patellar    Bursitis,    310. 

Penis,    amputation    of,    220. 

Jaws,    neural    anatomy    of,    75.  Peritoneum,   nerves   of,    i6v 

excision    of    lower,    89.  Perineum,    repair    of,    250." 

resection    of    upper,    81.  Pleural   exudate,    aspiration    of,    148. 

Plexus    blocking,    295. 
Preparation    of    field    of    operation,    28. 
Prevention      of     after-pain     with     local 

,,..  anesthesia,    44. 

Kidneys,    operations    on,    158.  Prostatectomy,    235. 

L 

O 
Laparotomy,     exploratory,     170. 

limitation    of   local    anesthesia   in,    19.  Quinine    and    urea    hydrochloride,    7. 

local    anesthesia    in,    170.  action     on     tissues,     7. 

Laryngotomy,    123.  epinephrin    with,    21. 

Larynx,     extirpation     of,     123.  injection    of,    n. 

Linea    alba,    hernia    of,    186.  other    salts    of    quinine,    14. 

Lipomas,     removal     of,     59.  rapidity    of   action    of,    13. 

Local    and    general    anesthesia    combin-  strength    of   solution    of,    10. 

ed,    22.  toxicity    of,    13. 


Indc.r 

R  nerve    blocking,    36. 

edematization,    37. 

Rectum,    operations    on,    264.  Teeth,    extraction    of,    77. 

carcinoma    of,    280.  lower,    81. 

dilatation    of,    270.  upper,    77. 

Ribs,    resection    of,     149.  Tendo    achillis,    operations    on,    303. 

Round     ligament,     shortening     of,     261.        Thoracentesis,     148. 
Alexander- Adams,     261.  Thoracoplasties,    144. 

Montgomery,    262.  Thyroid,    operations    on,     119. 

Toes,     ingrowing    nails,     299. 
Tongue,     operations     on,     90. 
S  Tonsils,   operations    on,    116. 

Tracheotomy,    121. 

Sacral    blocking,    208.  Tumors,    removal    of,    59. 

Sacral    blocking   in   pelvic   surgery,   263. 
Scalp,    tumors    of,    67. 

wounds  of,   65.  U 

Scar    hernias,    186. 

Sciatic    nerve,    injections    of,    311.  Upper   extremity,   operations  on,   287. 

Scrotum,    operations    on,    229.  Umbilical    hernia,    repair    of,    182. 

Schleich,   formulas   of.    4.  Ureter,    stones    in,    235. 

method    of   anesthesia,    37.  Urethral   caruncle,   262. 

Shock,    prevention   of,    51.  Urethrotomy,    233. 

Shortening  of  the   round   ligament,  261.  carcinoma    of,    261. 

Skin    grafting,     62.  Uterus,   curretage   of,   243. 

Skull,    operations    on,    70.  removal    of,    261. 

Spine,    operations    on,    143.  Urethral    caruncle,    262. 

Sphincter,    dilatation    of,    270. 
Stovain,    18. 
Subdiaphragmatic    abscess,    drainage    of,  V 

154- 

Suprapubic    cystotomy,    234.  Varicocele,    operation    on,    222. 

Syringes,    25.  Varicose    ulcers,    303. 

dental,    27.  veins,    306. 

with    extension,    26.  Yasectomy,    231. 

Venous    anesthesia,-  39. 
Vulva,    operations    on,    260. 
T 

Technic      of     administration  of      local  W 

anesthetics,    31. 

endermic   infiltration,    32.  Water    as    an    anesthetic,    19. 

subdermic    infiltration,    35.  Wens,   removal   of,   67.  » 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


196Qi, 


Form  L9-50m-ll,'50  (2554)444 


THE  LIBRARY 
UNIVERSITY  @F  CALIFORNIA 

LOS  ANGELES 


3"6v 


A     000  373  308     6 


